INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5 and 6, 2009 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 November 5, 2009.
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Plan of Correction
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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 observation and a physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents on 10/5/09 and 10/6/090.
The findings include:
At 1:00 PM on 10/5/09 it was observed that the dumpster was overflowing and the lids could not be closed. Garbage was piled around the dumpster as well. A mattress was stuffed behind the dumpster. At 2:00 PM on 10/5/09 the garbage had been removed from around the dumpster, but the mattress was still behind the dumpster and the dumpster was still too full to close the lids. At 8:00 AM on 10/6/09, the dumpster was still too full to close the lids.
The Facility Director and the Regional Property Manager was interviewed on 10/5/09 and 10/6/09 when they confirmed they had weekly pickup, on Wednesdays. They stated the garbage was due to be picked up on 10/7/09 and confirmed that only the material that was in the dumpster would be taken away.
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Plan of Correction
Beginning 10/7/09, Concept 90 Program Director and Central Region Property Manager will monitor and ensure that the facility dumpster is emptied on a regular and timely basis. In the event that the dumpster is filled before the scheduled removal day, York Waste Disposal will be contacted by the Property Manager for immediate removal of the trash to ensure DOH standards are adhered to. |
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 the physical plant tour and interviews with the Facility Director the project's Central Region Property Manager, the facility failed to ensure client confidentiality in that the second floor group room was equipped with three large windows that did not have covers. Clients in group treatment sessions would be visible to anyone on the second floor of the adjacent building:
The findings include:
The three windows in the second floor group room were not covered.
The Central Region Property Manager did provide blinds for those windows and the blinds were installed on 10/6/09, prior to the completion of the inspection.
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Plan of Correction
The Program Director will ensure condidentiality in all facility counseling areas by hanging blinds that cover the full length of the window. The Program Director will monitor this by making a weekly run throughout the facility to ensure that all counseling areas have secure window covers that remain intact. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on observation and a physical plant tour, the facility failed to clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area after the 11:00 AM to 12:00 PM lunch period.
The findings include:
A physical plant inspection was conducted on 10/5/09. At 1:30 PM the kitchen was inspected. A piece of raw chicken, (a drumstick), was lying in the kitchen sink. The kitchen sink had not been cleaned, containing other organic debris in addition to the raw chicken drumstick. At least three dirty dishes were in the kitchen.
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Plan of Correction
The Program Director and Cook Manager will ensure that all eating, drinking, and cooking utensils and all food preparation areas are cleaned within one hour after each meal has been completed. These utensils will be stored in a clean enclosed area. The cook manager will make inspections of these utensils and cooking areas prior to and following every meal on a daily basis for a three month period. Any deviations from DOH standards will be reported immediately to the Program Director. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection and interviews with the Facility Director and the project's Central Region Property Manager, the facility failed to ensure that interior exits were lighted at all times.
The finding includes:
The second exit from the basement, through the tunnel, was not lighted at the time of the 1:30 PM inspection on 10/5/09. This is the emergency interior exit from the basement level and must be lighted at all times.
The light had been replaced and was functional during a second walk through on 10/6/09 at 3:00 PM.
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Plan of Correction
The Program Director will make weekly inspections of all interior exits to ensure appropriate lighting. The Central Region Property Manager will follow up with monthly inspections of all facility lighting with an emphasis on emergency and interior exit lighting for a period of six months. Any burned out lighting will be corrected immediately by the staff on duty. |
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 on a review of facility policy, client records, and interviews with the Facility Director and the Clinical Supervisor, the facility failed to ensure that the psychosocial evaluations were completed in accordance with facility policy and procedures.
The findings include:
On October 6, 2009 eight client records were reviewed for the client's psychosocial evaluation. The facility failed to document psychosocial evaluations that were evaluative and failed to include all components as per the facility's policy and procedure in four of eight client records reviewed. The facility failed to document a psychosocial evaluation to include a composite picture, client problems/needs, assets/strengths, support systems, attitude toward treatment and/or the counselor's conclusions/impressions, and to provide an evaluative assessment as per facility policy, in four of eight client records reviewed
Findings:
Facility policy and procedure titled: "DELIVERY OF REHABILITATION CLINICAL PROCESSESS [sic] & PROCEDURES", developed January, 2009, stated:
"The biopsychosocial, with accompanying assessment and diagnostic summary must be completed within 3-5 days of the client's admission."
Facility policy and procedure titled: "POLICY & PROCEDURE FOR PSYCHOSOCIAL ASSESSMENT", dated January, 2009, stated:
"Each Psychosocial Assessment shall address the following aspects:"
1. Client Description and Appearance
2. Referral Source
3. Number of Prior Admissions
4. Presenting Problems and Underlying Problems
5. Treatment Issues/ Clinic
6. Client Response during Intake
7. Attitude and Receptivity Towards Treatment
8. Motivating Factors for Treatment
8. Ability to Participate in Treatment [sic]
9. Client Coping Mechanisms / Ego Defenses
10. Negative Factors Inhibiting Treatment
11. Client Strengths, Abilities, Needs and Preferences(SNAP) Contributing to the Problem
Resolution
12. Available Support Systems
13. Treatment Recommendations and Services
14. Prognosis
15. Clinical Impression (DSM IV axis)
16. Admission Note
The psychosocial evaluation in client record # 1 failed to address and evaluate the client's support systems and failed to provide evaluations of the client's coping mechanisms and attitude toward treatment. The client was admitted to treatment on 8/20/09 and the psychosocial evaluation was dated 8/20/09.
The psychosocial evaluation in client record # 2 failed to evaluate the client's problems and needs and failed to evaluate the client's coping mechanisms, negative factors and attitude toward treatment. The client was admitted on 8/19/09 and the psychosocial evaluation was dated 8/19/09.
The psychosocial evaluation in client record # 7 failed to address the client's negative factors. There were no evaluations of the client's problems and needs, assets and strengths, and coping mechanisms. The client was admitted on 7/8/09 and the psychosocial evaluation was dated 7/9/09.
The psychosocial evaluation in client record # 8 failed to address the client's assets and strengths, and support systems. There were no evaluations of the client's problems and needs and coping mechanisms. The client was admitted on 8/24/09 and the psychosocial evaluation was dated 8/24/09.
The clinical supervisor confirmed that the psychosocial evaluations had not been documented in accordance with the facility's policy and procedures.
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Plan of Correction
The Program Supervisor will conduct a training for clinical staff to ensure that each psychsocial assessment will include all components and is evaluative and presents a composite picture of the client. This training will be held on 10/30/09. The Program Director and Program Supervisor will ensure that all bio psychsocial histories and assessments are completed within 3-5 days of the clients admission date. This will be achieved by auditing 100% of new admission charts on a weekly basis for a period of six months. |
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 on a review of facility policy and procedures, client records, and interviews with the facility director and the clinical supervisor, the facility failed to ensure that individual treatment and rehabilitation plans were developed with the client following the completion of their psychosocial evaluation in 3 of 8 client records reviewed.
The findings include:
Facility policy titled "DELIVERY OF REHABILITATION CLINICAL PROCESSESS [sic] & PROCEDURES (Long-Term / Short-Term Residential Programs) II. (2)" stated: That the Initial individualized treatment plan is to be completed by the primary counselor and client within the first 3-5 days.
Facility Policy titled, "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN", dated January, 2009, stated:
An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social and assessment and the client's problem list. The plan will be discussed with the client and changes made upon client request as appropriate
The treatment plan will be signed by the Client, the Primary Counselor, the Clinical Supervisor, physician (when applicable) and placed in the client record. Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential) or by the third session (outpatient).Chesapeake region requires an initial TP within 24 hours).
On October 6, 2009 eight client records were reviewed for documentation of individual treatment plans that were developed with the client following the completion of the bio-psychosocial evaluations.
Three client records included documentation of treatment plans that had been completed prior to the completion of the psychosocial evaluations, upon which the treatment plan are based.
The individual treatment plan in client record # 3 was dated 8/25/09. The psychosocial evaluation was dated 9/3/09. The client was admitted on 8/25/09. The treatment plan was completed prior to the completion of the psychosocial evaluation.
The individual treatment plan in client record # 6 was dated 8/19/09. The psychosocial evaluation was dated 8/21/09. The client was admitted on 8/18/09. The treatment plan was completed prior to the completion of the psychosocial evaluation.
The individual treatment plan in client record # 7 was dated 7/8/09. The psychosocial evaluation was dated 7/9/09. The client was admitted on 7/8/09. The treatment plan was completed prior to the completion of the psychosocial evaluation.
The clinical supervisor confirmed that the treatment plans had been completed prior to the completion of the psychosocial evaluation.
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Plan of Correction
Treatment Plans will be developed after the bio psychsocial history and assessment are completed. The treatment plan will be developed with the client and will individually address the clients needs. The Program Supervisor will conduct audits on 100% of new admission charts for a period of six months. |
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 on a review of client records and interviews with the facility director and the clinical supervisor, the facility failed to include the proposed type of support services on the treatment plans in eight of eight client records.
The findings include:
Eight client records were reviewed on October 6, 2009. The proposed type of support services were to be included on the individualized treatment plans in eight of eight client records, but were not documented on the individualized treatment plans in any of the eight client records reviewed.
The treatment plan in client record # 1 did not include documentation of the proposed support services. The client was admitted to treatment on 8/20/09 and the treatment plan was dated 8/22/09.
The treatment plan in client record # 2 did not include documentation of the proposed support services. The client was admitted on 8/19/09 and the treatment plan was dated 8/19/09.
The treatment plan in client record # 3 did not include documentation of the proposed support services. The treatment plan was dated 8/25/09. The client was admitted on 8/25/09.
The treatment plan in client record # 4 did not include documentation of the proposed support services. The treatment plan was dated 7/8/09. The client was admitted on 7/8/09.
The treatment plan in client record # 6 did not include documentation of the proposed support services. The treatment plan was dated 8/19/09. The client was admitted on 8/18/09.
The treatment plan in client record # 7 did not include documentation of the proposed support services. The client was admitted on 7/.8/09 and the treatment plan was dated 7/8/09.
The treatment plan in client record # 8 did not include documentation of the proposed support services. The client was admitted on 8/24/09 and the treatment plan was dated 8/24/09.
The treatment plan in client record # 9 did not include documentation of the proposed support services. The client was admitted on 8/17/09 and the treatment plan was dated 8/19/09.
The facility director and the clinical supervisor confirmed that the proposed support services had not been documented on the individualized treatment plan.
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Plan of Correction
Treatment plans will be developed to include proposed types of support services as determined by the clients needs. The Program Supervisor will conduct an in service training seminar on 10/29/09 to assist the clinical staff in identifying all area support services available to meet the needs of Concept 90 clients. Adherence to this practice will be monitored by the Program Supervisor doing a ramdom weekly chart audit for a period of three months. If the DOH standard is being met at this time, random monthly chart audits will resume. |
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 on a review of facility policy and procedures, client records, and interviews with the facility director and the clinical supervisor, the facility failed to include a comment relative to each individual's response or participation in the group session in the group progress notes as per facility policy and procedures in six of eight client records reviewed.
The findings include:
Facility Policy titled, "CLIENT COUNSELING LOGS / PROGRESS NOTES ", dated January, 2009, stated:
Group Activities / Sessions:
For group sessions, individual notes need not be written for each client. One group note will suffice provided that it includes a comment relative to each individual's response or participation in the group session. Group Feedback sheets are used to document the type and focus of the group, the client's specific feedback and the Counselor's assessment of the client's involvement.
On October 6, 2009 eight client records were reviewed for the content of progress notes. Group progress notes in six of eight client records did not include comments relative to the individual's response or participation in the group treatment session.
The group progress notes in client record # 1 did not include comments relative to the individual's response or participation in the group treatment session. These comments were not documented on the group progress notes from the following group treatment sessions: 9/9/09; 9/11/09; 9/16/09; 9/21/09 and 9/23/09. The client was admitted to treatment on 8/20/09.
The group progress notes in client record # 2 did not include comments relative to the individual's response or participation in the group treatment session. These comments were not documented on the group progress notes from the following group treatment sessions: 8/31/09; 9/11/09; and 9/21/09. The client was admitted on 8/19/09.
The group progress notes in client record # 3 did not include comments relative to the individual's response or participation in the group treatment session. These comments were not documented on the group progress notes from the following group treatment sessions: 8/31/09; 9/9/09; and 9/23/09. The client was admitted on 8/25/09.
The group progress notes in client record # 7 did not include comments relative to the individual's response or participation in the group treatment session. These comments were not documented on the group progress notes from the following group treatment sessions: 8/31/09; 9/16/09; and 9/23/09. The client was admitted on 7/.8/09.
The group progress notes in client record # 8 did not include comments relative to the individual's response or participation in the group treatment session. These comments were not documented on the group progress notes from the following group treatment sessions: 9/9/09; 9/16/09; and 9/21/09. The client was admitted on 8/24/09.
The group progress notes in client record # 9 did not include comments relative to the individual's response or participation in the group treatment session. These comments were not documented on the group progress notes from the following group treatment sessions: 8/31/09; 9/11/09; and 9/23/09. The client was admitted on 8/17/09.
The clinical supervisor confirmed that the group progress notes in those records did not include comments relative to the individual's response or participation in the group treatment session.
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Plan of Correction
A clinical staff training will be conducted on 10/28/09 by the Program Supervisor to incorporate how to address individual interactions in group and proper documentation in the group progress note. Additionally, training will be held on a monthly basis by the Program Supervisor in clinical staff meeting. Group progress notes will be monitored for compliance by the Program Supervisor on a weekly basis as they are turned in. |
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 on a review of facility policy and procedures, client records, and interviews with the facility director and the clinical supervisor, the facility failed to include the contact person and the re-entry process on the after care plans as per facility policy and procedures in two of two client records.
The findings were:
Facility Policy titled, "AFTERCARE PLANS", dated January, 2009, stated:
Aftercare planning is initiated during the first week of treatment. In an effort to promote continued growth of the progress made while in treatment, the Gaudenzia attempts to complete individualized aftercare plan with each client regardless of the discharge status or treatment disposition.
Initial discharge plan begins within 24 hours of admission while formal arrangements are made upon determination of the client's readiness for discharge. This is the individual's plan for the future, including identification of the client's personal goals and objectives. It should focus on sustaining and building on the progress achieved during treatment and should have input from all significant persons, especially the client.
While some client's may refuse aftercare plan (i.e. ... when leaving against staff advice), each client being considered for treatment completion must complete an individualized aftercare plan. In preparation for aftercare plan, the client is asked to complete a "Mock Continuing Care Plan" containing information on: living arrangements, employment, recreation/leisure activities, AA/NA sponsor, contacts, and planned meeting attendance.
The formal Discharge/Continuing Care Plan to be completed by the Counselor in conjunction with the client, shall contain:
Assessment of Client's Commitment to Recovery
Family Involvement
Living Arrangements
Employment/Education Plans
Recreation/Leisure Activities
Plans for 12 Step Program Participation
D & A Service/Treatment Arrangements
Ancillary Service Arrangements
Future Goals, Action Steps and Projected Dates of Achievement
Treatment Summary
Prognosis
Referral and Client Comments
Project Services Post Discharge
Readmission Procedures (criteria for re-entry into the program)
Provision for the periodic re-evaluation and termination of the plan
Client/Staff Signatures
The original aftercare plan shall be maintained in the client's record. A copy of the plan should be given to the client.
On October 6, 2009 two closed client records were reviewed which required documentation of aftercare plans. The aftercare plans documented in those client records did not include documentation of the contact person and the re-entry process.
The aftercare plan in client record # 4 was dated 9/29/09. The client was admitted on 7/8/09 and discharged on 10/1/09. Facility policy and procedure required that the aftercare plan be completed prior to discharge. The aftercare plan documented in the client record was incomplete in that the contact person and the re-entry process was not documented on the aftercare plan or in the client record.
The aftercare plan in client record # 5 was dated 9/20/09. The client was admitted on 7/13/09 and discharged on 10/1/09. Facility policy and procedure required that the aftercare plan be completed prior to discharge. The aftercare plan documented in the client record was incomplete in that the contact person and the re-entry process was not documented on the aftercare plan or in the client record.
The facility director and the clinical supervisor confirmed that the aftercare plans did not include documentation of the contact person or the re-entry process.
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Plan of Correction
A staff training was held on 10/16/09 facilitated by the Program Supervisor to address aftercare plans to include the facility contact person and re-entry process for clients completing treatment. This will be monitored by the Program Supervisor who will audit the charts of all clients leaving treatment on an ongoing basis. This will also be monitored by the Program Supervisor and Program Director during monthly chart audits for quality assurance purposes. |