INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted from September 10 - 11, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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:
|
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 upon the physical plant inspection, the facility failed to keep the grounds of the facility safe and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
The access road and parking areas that were utilized by the facility were inspected on September 12, 2012, at approximately 8:10 AM.
The facility is located off of a main highway and is accessed via a paved road that proceeds through the grounds of a former hospital. The facility's main access road begins toward the rear of the hospital, proceeds around a right hand turn and up an incline to the facility. The road then continues around the right side of the facility and down to and through a lower parking area. The access road then ends where it reconnects with the hospital's road that leads to and from the highway.
The lower portion of the access road and lower parking area contained a minimum of 4 potholes that measured over 36 inches wide and 1 pothole that was smaller. The smallest of the potholes was located toward the bottom of the access road as it leads toward the parking area. The last pothole, which measured over 36 inches wide, was located at the end of the access road, where it reconnects to the hospital road. The potholes presented a hazard to both people and vehicles.
The findings were confirmed by the Facility Director and the Property Manager. The Property Manager had initiated repairs by the time the inspection was concluded.
|
Plan of Correction
The building exterior and grounds should be clean, safe, and sanitary at all times for the safety and well-being of residents, employees and visitors... The potholes located on the lower portion of the access road were filled with an asphalt substance. The work was completed by the end of the work day on September 12, 2012.
The Gaudenzia Physical Plant Manager will include checking the condition of the access road during the completion of his monthly facility maintenance run. The Program Director will notify the Physical Plant Manager immediately if a sudden problem with the road arises. In addition, the Program Director will ensure that safety issues concerning the access road are included in the monthly report to the agency-wide Safety Committee. The Physical Plant Manager will be responsible for arranging road repairs when needed. This correction is in effect as of October 1, 2012. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based upon a review of inspection records for the medication storage area, the facility failed to obtain a quarterly inspection of the medication storage area.
The findings include:
Inspection records for the facility's medication storage area were reviewed on September 11, 2012. The facility was unable to provide documentation of a quarterly inspection for the time frame of April 1 to June 30, 2012.
The findings were confirmed by the Facility Director during the inspection.
|
Plan of Correction
Per regulation, an inspection of the medication storage area will be conducted quarterly. A dated record of the inspection will be maintained in the medical office. The facility nursing staff will be responsible to schedule the review with a registered pharmacist. In addition, the facility nursing staff will continue to conduct their own medication inspections monthly and continue to maintain dated records of these inspections in the medical office as per the Fountain Springs procedure. The policy and procedure for inspection of the medication storage area will be reviewed with the nursing staff in meeting on September 28, 2012. The nursing staff will provide written acknowledgment that the regulation and procedures were reviewed and understood. The Program Director will ensure compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to document physical examinations as per facility policy.
The P&P Manual was reviewed on September 10, 2012.
The facility policy titled, "Physical Exams - Labs" with the subtitle, "Physical Examination Laboratory Studies" included the following language:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Other exceptions are:
1. The client received a complete physical examination no longer than one month prior to
admission; that the program staff can obtain the results in writing; and the nurse on duty is able to ascertain no noticeable medical problems.
2. Any physical examination not performed by the Gaudenzia physician will be reviewed and signed off by him/her as soon as possible following receipt of such documentation."
Ten records requiring documentation of physical examinations were reviewed from September 10 - 11, 2012. Four of ten records, specifically # 's 4, 7, 8, and 9, contained physical exams that were completed late and / or that did not include documentation of the physician's impressions.
Client # 4 was admitted on June 28, 2012, and the physical exam was due by July 6, 2012 (one day added due to holiday). The record contained documentation of a physical exam that was late as it was completed on August 13, 2012.
Client # 7 was admitted on July 2, 2012, and the physical exam was due by July 10, 2012 (one day added due to holiday). The record contained documentation of a physical exam that was late as it was completed on August 13, 2012. In addition, the physical exam did not include documentation of the physician's impressions.
Client # 8 was admitted on July 3, 2012, and the physical exam was due by July 11, 2012(one day added due to holiday). The record contained documentation of a physical exam that was late as it was completed on August 13, 2012. In addition, the physical exam did not include documentation of the physician's impressions.
Client # 9 was admitted on July 6, 2012, and the physical exam was due by July 13, 2012. The record contained documentation of a physical exam that was late as it was completed on August 13, 2012. In addition, the physical exam did not include documentation of the physician's impressions.
The findings were reviewed with the Clinical Supervisor during the record review.
This is a repeat citation from the May 22-23, 2012 annual licensing inspection and the June 1, 2011 annual licensing inspection.
|
Plan of Correction
Clients entering Gaudenzia Fountain Springs shall receive a complete physical examination by a qualified physician within seven (7) days of admission; documentation of physician overall impression of client will be recorded on every physical form. As a means to meet the regulation, effective August 20, 2012, Fountain Springs contracted with a qualified physician to provide medical services for the residents including the competion of physical examinations. As of August 20, 2012, physical examinations, including documentation of physician impressions, have been completed on every new admission. The nursing staff reviews the physical exam documentation for completeness and files it promptly in the client record. To ensure continued compliance with the physical policy, the Clinical Supervisor and/or Program Director will review new client charts during weekly clinical meetings. |
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.
|
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 as per the individual treatment and rehabilitation plan.
The findings include:
The P&P Manual was reviewed on September 10, 2012.
The policy titled, "Counseling Services" included 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.
- Individual counseling ..... shall be documented in the client record in an Individual Counseling Progress Note. (Residential DOH, PA)
- All therapy services shall be noted on the Record of Services Provided form."
Six client records requiring documentation of counseling services received by clients were reviewed from September 10-11, 2012. Six of six records, specifically #'s 1, 2, 3, 4, 5 and 6, did not contain documentation of static group counseling sessions that were to be provided to the client as per the treatment plan.
Client # 1 was admitted on June 22, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed by the client on June 25, 2012. The treatment plan specified that the client would receive 1 static group counseling session per week and 2 individual counseling sessions per month. The record did not contain documentation of static group sessions for the following weeks:
July 1-7, 2012; July 22-28, 2012
July 29 - August 4, 2012
August 5-11, 2012; August 12-18, 2012; August 19-25, 2012
August 26 - September 1, 2012
Client # 2 was admitted on June 26, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed by the client on June 27, 2012. The treatment plan specified that the client would receive 1 static group counseling session per week and 2 individual counseling sessions per month. The record did not contain documentation of static group sessions for the following weeks:
July 1-7, 2012; July 8-14, 2012; July 15-21, 2012; July 22-28, 2012
July 29 - August 4, 2012
August 5-11, 2012; August 12-18, 2012; August 19-25, 2012
August 26 - September 1, 2012
Client # 3 was admitted on June 27, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed by the client on June 28, 2012. The treatment plan specified that the client would receive 1 static group counseling session per week and 2 individual counseling sessions per month. The record did not contain documentation of static group sessions for the following weeks:
July 1-7, 2012; July 8-14, 2012; July 15-21, 2012; July 22-28, 2012
July 29 - August 4, 2012
August 5-11, 2012; August 12-18, 2012; August 19-25, 2012
August 26 - September 1, 2012
Client # 4 was admitted on June 28, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed by the client on June 29, 2012. The treatment plan specified that the client would receive 1 static group counseling session per week and 2 individual counseling sessions per month. The record did not contain documentation of static group sessions for the following weeks:
July 1-7, 2012; July 8-14, 2012; July 15-21, 2012; July 22-28, 2012
July 29 - August 4, 2012
August 19-25, 2012
Client # 5 was admitted on July 13, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed by the client on July 16, 2012. The treatment plan specified that the client would receive 1 static group counseling session per week and 2 individual counseling sessions per month. The record did not contain documentation of static group sessions for the following weeks:
July 15-21, 2012; July 22-28, 2012
July 29 - August 4, 2012
August 12-18, 2012; August 19-25, 2012
August 26 - September 1, 2012
Client # 6 was admitted on August 7, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed by the client on August 9, 2012. The treatment plan specified that the client would receive 1 static group counseling session per week and 2 individual counseling sessions per month. The record did not contain documentation of static group sessions for the following weeks:
August 12-18, 2012; August 19-25, 2012
August 26 - September 1, 2012
The findings were confirmed by the Clinical Supervisor during the record review.
|
Plan of Correction
Per the Gaudenzia policy titled, "Counseling Services", counseling services shall be provided for each client according to the frequency and nature identified on the client's treatment plan. All therapy services shall be noted on the Record of Services Provided form. The Clinical Supervisor will review this policy with the clinical staff in clincial meeting on September 27, 2012 and will obtain written verification from counselors that the policy was reviewed and understood. The Clinical Supervisor and/or Program Director will ensure compliance through monthly CQI case audits and ongoing staff supervision. |