INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19 & 20, 2008 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 and a plan of correction is due on July 22, 2008.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based upon a review of five personnel records on May 16, 2008 & June 19, 2008, three of five records reviewed contained individual training plans that were not developed in accordance with the facility's policy and procedure manual. Training plans were developed late in three records reviewed, specifically client records #3, 4 & 5.
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Plan of Correction
In the following year the Director along with the staff will develop a training plan for each staff person in accordance with the agencies policies. Training plans will be done at the beginning of the year and immediately upon new staff hire. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based upon a review of 5 personal records on June 19, 2008, one of five employees requiring the mandatory 6 hour HIV/AIDS training and the four hours of TB/STD training had not yet completed it within the required time frame of one year from the date of hire. Employee #2 had not completed the mandatory 6 hours of HIV/AIDS training and four hours of TB/STD training within one year of the original hire date of 6/18/07.
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Plan of Correction
Employee #2 has been registered for HIV/AIDS and TB/STD for August 15 and 20th, 2008. Employees will be registered for training based on the agencies policy and procedures. |
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 a review of eight client records on June 19 & 20, 2008 and an interview with a corporate representative on May 29, 2008, the facility failed to ensure that they obtained an informed and voluntary consent from the client for the disclosure of information contained in the client records.
Seven client records were reviewed for consent to release information forms, of those seven, five client records #1, 2, 3, 4 & 5 all contained a medical release form for the release of client identifying information for urine drug screens without identifying the laboratory that the facility intended to use. The consent stated that the information could be released to a laboratory of the facility's choosing. The facility did not have a Qualified Service Organization Agreement in place with any laboratories on file.
Four of seven client records reviewed, #1, 5, 6 & 7, all contained consents to release information that were signed by the client but did not list who the information was to be released to.
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Plan of Correction
Counselors will ensure that all clients sign consent forms that clearly outline where the information is going and who is requesting it. In addition the laboratory for all urine drug screenings will be noted on medical release forms and identified as the laboratory where urine drug screenings are sent. Clinical Supervisdor will review records on a weekly basis for a period of 3 months to ensure forms are being properly completed. If at the end of three months no violations were noted the Clinical Supervisor will pull records randomly on a quarterly basis to ensure continued compliance. Also, they will be monitored at our monthly CQI meetings. |
709.32(a) LICENSURE Medication Control
709.32. Medication control.
(a) Projects which furnish pharmaceutical services shall comply with all applicable Federal, State and local ordinances, statutes and regulations regarding the storing, compounding, administering or dispensing of medication.
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Observations
Based upon a review of eight client records on June 19 & 20, 2008, including the medical records, the facility failed to follow the facility policy and procedure stating: "If a client is unavailable or refuses to take medication at the correct time, the nurse shall circle and initial the med sheet and document in the comments section the reason the medication was not given".
Of the eight client records reviewed, three clients required medications and that a medication administration record be maintained. Two of those three records, #1 & 5, lacked the required documentation for days where there was no entry into the medication administration record.
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Plan of Correction
The Medical Supervisor will retrain staff to correctly document in the medication log when a client refuses medication or is unavailable. The Nursing Supervisor will review records on a weekly basis for a period of 3 months to ensure forms are being properly completed. If at the end of three months no violations were noted the Nursing Supervisor will pull records randomly on a quarterly basis to ensure continued compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of eight client records on June 19 & 20, 2008 the facility failed to complete a physical examination within seven days of admission in one of eight client records reviewed, specifically client records #1. The physical examination document in client record #2 was dated two days prior to the admission date and there was no documentation of an explanation for this anomaly. The physical examination document in client record #5 had been altered with 'white-out'.
Client #1 was admitted on 1/4/08, the physical examination document was dated 1/14/08.
Client #2 was admitted on 3/18/08 but the physical examination document was dated 3/16/08.
Client #5 was admitted on 1/10/08, the date on the physical examination document was obscured with 'white-out' and the date of 1/16/08 written over the 'white-out'.
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Plan of Correction
Facility Director will review the importance of completing the physical exam within 7 days of admission date, the importance of properly documenting the proper dates, and the use of white out is not permissible. The facility Director will have the Nursing Supervisor review all physicals for a period of a month to ensure that they are properly completed and in a timely manner. If at the end of a month there are no problems then the Nursing Supervisor will review randomly. |
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:
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Observations
Based upon a review of eight client records on June 19 & 20, 2008, five records were reviewed for individualized treatment plans. Of the five reviewed, the facility failed to develop an individualized, comprehensive treatment plan with the client within 5 days from the date of admission as required by facility policy and procedure in five of five records reviewed.
The treatment plans in record #4 was signed on 6/12/08 with the date of admission being 5/9/08.
The treatment plans for client records #1, 2, 3, 4 &5 were not individualized, they were identical.
The treatment plan for client records #3 was completed prior to the completion of the psychosocial evaluation.
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Plan of Correction
Clinical Supervisor will review with staff the importance of completing the comprehensive treatment plan within the facility time frames. In addition it will be emphasized that the treatment plans will be individualized and based upon the psychosocial evaluation. Clinical Supervisor will review records on a weekly basis for a period of 3 months to ensure forms are being properly completed. If at the end of three months no violations were noted the clinical Supervisor will pull records randomly on a quarterly basis to ensure continued compliance. |
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 a review of eight client records on June 19 & 20, 2008, three required that a discharge summary be completed. The facility failed to complete a discharge summary in one of three records reviewed, specifically client record #6.
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Plan of Correction
Clinical Supervisor will review the importance of completing discharge summary with in 7 days for all clients discharged. Clinical Supervisor will review records on a weekly basis for a period of 3 months to ensure forms are being properly completed. If at the end of three months no violations were noted the Clinical Supervisor will pull records randomly on a quarterly basis to ensure continued compliance. Also, they will be monitored at our monthly CQI meetings. |