INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5-6th 2019 of Gaudenzia, Inc. Fountain Springs by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to follow their policy in regard to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated, "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16th, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated time frame each year. |
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 June 6, 2019 the facility failed to ensure that the building is kept in good repair at all times as demonstrated by:
1. Individual air conditioner lids in each room could not be closed and exposed internal workings and wires of the unit.
2. Second Floor bedroom #7 had a hole in the ceiling.
3. The childcare room had cracks and paint falling off the wall that was held together with electrical tape.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Facility Plant Manager has already spoken with the facility air conditioning vendor (Trane) and new air conditioner lids have been ordered for the sixteen (16) rooms which required them. The air conditioning vendor will contact the facility when the order comes in to schedule a date for installation. Expected date of completion for the above work is 9/15/19. Until installation can occur all broken lids will be taped down on August 12 2019 to prevent anyone from placing a finger, hand, etc. into the area. In addition, house managers will visibly check those areas during their routine house runs to ensure the lids are still closed. The House Manager Supervisor will ensure compliance with this by reviewing the daily house run sheets and discuss any issues with compliance with the Program Director at the weekly administrative meeting.
2. A new ceiling tile was installed in the second floor #7 bedroom by the time the on-site inspection was completed on June 6, 2019.
3. The Facility Plant Manager is in the process of obtaining bids from local contractors to repair the damaged part of the wall in the Child Care area. Expected date of completion for that project is 10/31/2019. Until completion of the project that corner of the room will be partitioned off on 8/12/2019 to ensure that no persons can physically be near the damaged drywall. Staff will visibly check this area to ensure that the partition is in place when they make routine daily house runs. The House Manager Supervisor will ensure that this regulation is being enforced by reviewing the house run sheets and bringing any noncompliance with it to the Program Director's attention during the weekly administrative meeting. |
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 plan inspection on June 6, 2019, it was observed that the facility failed to maintain trash dumpsters in a manner to prevent the penetration of insects and rodents. The lids to the dumpsters were observed open and not covered.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will hold a mandatory staff meeting on August 29, 2019 to discuss the proper maintenance of the trash dumpsters and review regulation 705.2(4). Also, the trash dumpster area will also be added to both the client and staff house run sheet to ensure the area is secure. A supervisory note will be placed in each staff personnel file documenting awareness and understanding of the regulation. The Program Director will ensure compliance of this regulation by reviewing the house run sheets with the House Manager Supervisor at the weekly Administrative Meeting. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted June 6, 2019, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as a counseling session in the counselor ' s room next to the downstairs group room could be heard from the group room and hallway.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will hold a clinical meeting with the Clinical Supervisor, all counselors, and the nurse to review regulation 705.4(3). In addition, white noise machines will be purchased and put to use in each clinical office and the nursing office by September 30, 2019. A supervisory note will be placed in each of the above staff's personnel file documenting awareness and understanding of this regulation. The Clinical Supervisor will do random clinical wing runs to ensure that the machines are being utilized and that the counseling sessions are private. The Clinical Supervisor will notify the Program Director of any noncompliance with this regulation at the weekly Administrative Meetings. On August 12, 2019 the clinicians will be instructed to keep all doors and windows closed while in session until the noise machines are received and put into use in order to ensure client privacy. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel files, employee #1 was not trained in the use of fire extinguishers upon employment. Employee #1 was hired on March 19, 2019 and was still employed at the time of the inspection. There was no documentation that he employee received the training as of the date of this inspection on June 6, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10(c)(4)-705.28(c)(4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of personnel files on June 6, 2019, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 19, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1 ' s personnel file indicating that the employee had been trained on what to do during emergencies as of the date of this inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10(c)(4)-705.28(c)(4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on June 6, 2019, the 3rd floor bathroom had a toilet stall that was locked from the inside and unable to open as well as a toilet with the top of the toilet tank removed and sitting on the floor
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bathroom stall on the 3rd floor which was inspected on June 6, 2019 with the stall door locked and the toilet tank lid off was found to be done so, in error. Facility staff unlocked the stall door and placed the toilet tank lid back on, and the toilet was found to be in working order. This toilet was checked for functionality on June 6, 2019. Staff on duty will visibly check the area during daily house runs to ensure that the toilet is functional and accessible. The House Manager Supervisor will review the daily house run sheets and will review any noncompliance with the Program Director at the weekly Administrative Meeting. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of seven client records, the facility's client rights documentation, included in the orientation packet, failed to include all the required client rights. The facility failed to include that:
Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
Clients have the right to appeal a decision limiting access to their records to the director.
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they may take in this regard. The document now states that, "The following rights are affirmed...The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the Director. Clients have the right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
The facility failed to document a medication record with staff and client acknowledging the medication was taken or documentation for the reason why the client did not receive the medication in seven out of seven client records.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will hold a mandatory staff meeting on 8/29/19 to review regulation 709.32(c)(4). The facility nurse will conduct an in-service at this meeting with all staff to review the proper way to document whether a client received medication or not. A supervisory note will be placed in each staff personnel file documenting awareness and understanding of this regulation. The facility nurse will ensure compliance with this regulation by conducting weekly audits of the medication administration record and will provide additional one on one training with staff when necessary. The Program Director will ensure compliance of this regulation by reviewing the client medication administration record with the facility nurse at the weekly Administrative Meeting. |
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 on a review of seven client records on, the facility failed to document treatment and rehabilitation plan updates within the regulatory timeframe in four of six applicable client records reviewed.
Client #1 was admitted on December 13, 2018 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on March 6, 2019 and the next update was due no later than April 6, 2019; however, there the update was not completed until April 22, 2019.
Client #2 was admitted on December 28, 2018 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on January 17, 2019 and the next update was due no later than February 17, 2019; however, there was no update completed until March 20, 2019.
Client #5 was admitted on August 1, 2018 and was discharged on January 25, 2019. A treatment and rehabilitation plan update was completed on November 23, 2018 and the next update was due no later than December 23rd, 2018; however, there was no update documented until January 4, 2019.
Client #7 was admitted on October 11, 2018 and was discharged on April 1, 2019. A treatment and rehabilitation plan update was completed on February 6, 2019 and the next update was due no later than March 6, 2019; however, there was no update documented until March 28, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will hold a clinical meeting with the Clinical Supervisor and all the counselors to review regulation 709.52(b) and will obtain written notification that regulation is understood by 8/27/19. A supervisory note will also be placed in each counselor personnel file documenting awareness and understanding of this regulation. The Clinical Supervisor will ensure compliance of this regulation by holding a weekly clinical meeting to review what treatment plans are due for the following week. In addition, the Clinical Supervisor will do weekly checks in the Electronic Health Care system to ensure treatment plan reviews were completed, signed, and submitted. The Program Director will ensure compliance of this regulation by reviewing what treatment plan needs an update with the Clinical Supervisor at the weekly Administrative Meeting. |
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 on a review of client records, the facility failed to provide a complete client record, which is to include verification that work done by the client is an integral part of the treatment and rehabilitation program for seven out of seven client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor will meet with all clinical staff to review regulation 709.53(a) on August 13, 2019. The clinicians will be instructed to utilize more therapeutic language in their clinical documentation; in particular when documenting the assignment of the client therapeutic work chore and what therapeutic goal is hoped to be accomplished ie: independent living skills, etc. A supervisory note will be placed in each clinician personnel file documenting awareness and understanding of this regulation. The Clinical Supervisor will ensure compliance with this regulation by conducting monthly CQI chart audits and discussing any noncompliance issues with this regulation with the Program Director at the weekly Administrative Meeting. |