INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 1, 2012 to August 2, 2012 by staff from the Division of Drug and Alcohol Licensure. Based on the findings of the on-site investigation, it has been determined that the allegations against Gaudenzia, Inc. Broad Street were partially substantiated. The following deficiencies were identified during this investigation:
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Plan of Correction
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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 observations on August 1, 2012, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients and employees and visitors.
The findings include:
A physical plant inspection was conducted on August 1, 2012. On August 1, 2012, 10 male residential bedrooms and 1 female residential bedroom were inspected. From approximately 3:00 P.M. to 4:00 P.M., the following items were identified.
1)One of the beds in male residential bedroom # 1 had stains of unknown substance on the pillow case and stains of unknown substance on the top of the mattress cover. Also, another bed in the bedroom had stains of unknown substance on the bed sheet.
2)One of the beds in male residential bedroom # 2 had stains of unknown substance on the bed sheet.
3)One of the beds in male residential bedroom # 5 had stains of unknown substance on the pillow case.
4) One of the beds in male residential bedroom # 6 had stains of unknown substance on the bed sheet.
5) One of the beds in male residential bedroom # 7 had dirt stains on the top of the mattress cover.
6) The bed in male residential bedroom # 8 had stains of unknown substance on top of the mattress cover.
8) One of the beds in male residential bedroom # 10 had stains of unknown substance on the bed sheet. Also, another bed in the bedroom had stains of unknown substance on the pillow case and dirt stains on the mattress cover.
9) One of the beds in female residential bedroom # 2 had stains of unknown substance on the bottom of the mattress. Also, another bed in the bedroom had urine stains on the top and bottom of the mattress.
The findings were confirmed during an interview with one of the house managers on August 1, 2012 at approximately 4:00 P.M.
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Plan of Correction
A meeting was conducted with the house mangers and clients to review the keepiings of the grounds, safety, and, sanitary of the facility. During the meeting, house managers were given instructions regarding the clients laundry day which include the clients washing their bed linens, ensuring that the grounds are clean and maintained at all times for the safety and well being of clients,employees, and visitors. Moving forward, the Supervisor will monitor the facility to ensure that the building exterior and grounds are free of hazards.
Bed #1: The entire matress cover was washed, dryed and replaced back on the bed.
Bed #2:A new pair of sheets and pillow case were provided for the bed.
Bedroom #5:All of the beds received new bed sheets, and pillow cases.
Bedroom #6: Received a new pair of sheets and pillow case.
Bedroom #7:All mattress covers were washed and replaced.
Bedroom #8:The mattress cover was replaced with a new one.
Bedroom #10: Received a new set of sheets and pillow cases.
Bedroom #10: All of the mattress covers were washed and replaced.
B
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on observations on August 1, 2012 and a review of the facility's "bed bug run books", the facility failed to ensure the physical plant was free of rodent and insect infestation.
The findings include:
A physical plant inspection was conducted on August 1, 2012. Ten male residential bedrooms and 1 female residential bedroom were inspected for evidence of bed bugs from approximately 3:00 P.M. to 4:00 P.M. The following items were identified as evidence of visible signs of bed bug infestation:
1)One of the beds in male residential bedroom # 6 had blood stains on the bottom of the mattress.
2)At approximately 4:00 P.M. it was observed on the second floor in male residential bedroom # 5 that a dead bed bug was visible on top of the mattress cover on one of the beds in the bedroom.
3)The bed in male residential bedroom # 9 had blood stains on the pillow case.
4)One of the beds in female residential bedroom # 2 had blood stains on a towel that covered the pillow.
The facility's "bed bug run books" were reviewed for evidence of bed bugs. The following are the dates and times that the facility indicated that bedbugs were seen:
1)On July 7, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that one of the bed frames in male residential bedroom # 2 was covered with baby bed bugs and adult bed bugs.
2)On July 8, 2012, it was observed by the facility during their "bed bug run" at 8:15 A.M. that one of the beds in male residential bedroom # 2 had bed bugs.
3)On July 9, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that a vacant bed in male residential bedroom # 2 had a bed bug.
4)On July 10, 2012, it was observed by the facility during their 3:00 P.M. to 11:00 P.M. shift "bed bug run" that in male residential bedroom # 2 there were seven dead bed bugs and in male residential bedroom # 5 there were twelve bed bug eggs. Also, on July 11, 2012 it was observed by the facility during their 11:00 P.M to 7:00 A.M. shift "bed bug run" that there were four bed bugs in male residential bedroom # 5.
5)On July 11, 2012, it was observed by the facility during their 3:00 P.M. to 11:00 P.M. shift "bed bug run" that bed bugs where in male residential bed room # 2.
6)On July 14, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that bed bugs where in male residential bedrooms # 2 and 5.
7)On July 15, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that bed bugs where in male residential bedroom # 1. Also, on the same day it was observed by the facility during the same shift that thirteen bed bugs where on the linen and pillow on one of the beds in male residential bedroom # 5.
8)On July 16, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that multiple bed bugs were on one of the head boards on one of the beds in female residential bedroom # 4. Also, on the same day, it was observed by the facility during the same "bed bug run" that multiple bed bugs where on the head board on one of the beds in male residential bedroom # 5.
9)On July 17, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that two live bed bugs where on the head board on one of the beds in male residential bedroom # 5.
10)On July 22, 2012, it was observed by the facility during their 3:00 P.M. to 11:00 P.M. shift "bed bug run" that bed bugs were in female residential bedroom # 4 and in male residential bedroom # 1.
11) On July 23, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that three live baby bed bugs where on the pillow on one of the beds in male residential bedroom # 5. Also, on the same day it was observed by the facility during the same shift that a bed bug was on a chair in the first floor conference room.
12) On July 23, 2012 and July 24, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that two live bed bugs where in male residential bedroom # 5.
13) On July 24, 2012, it was observed by the facility during their 3:00 P.M. to 11:00 P.M. shift "bed bug run" that there was a dead bed bug on the head board on one of the beds in female residential bedroom # 4. Also, on the same day, it was observed by the facility during the same shift that a bed bug was in male residential bedroom # 2.
14) On July 25, 2012, it was observed by the facility during their 11:00 P.M. to 7:00 A.M. shift "bed bug run" that two live bed bugs where on the head board on one of the beds in male residential bedroom # 5.
The findings during the physical plant inspection of the bed bug and stained items on the beds were confirmed during an interview with one of the house managers on August 1, 2012 at approximately 4:00 P.M. The facility "bed bug run" reports and the clearly visible blood stains on mattresses and pillows were evidence of visible signs of bed bug infestation.
The facility director and two division directors confirmed the findings of the "bed bug run books" on August 1, 2012 at approximately 5:00 P.M.
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Plan of Correction
On 8/16/12 and 9/6/12, the entire facility which included all bed room, and bed room furniture was treated for bed bugs. Moreover, the house managers continue to do the required bed bug runs twice per day on a daily basis, to ensure that the facility is free of rodent and insect infestation. The Program Supervisor will be responsible for ensuring that the bed bug runs are completed on a daily basis, and will initial the bed bug run sheet, after it is reviewed.
Bedroom #6: Received a new mattress cover due to blood stains that were noted.
Bedroom #9: Received received new sheets and pillowcase due to blood stains that were noted.
Bedroom #2, The client received a new towel due to blood stains noted on the towel that was in her possession. The stained towel was discarded.
The dead bed bug that was found in male residential bedroom #5 was removed and discarded.
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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 client records, the project failed to ensure that a treatment plan was documented in one of three client records.
The findings include:
On August 2, 2012, three client records were reviewed. The facility did not include documentation of a treatment plan in one of three client records, specifically client record # 2.
Client # 2 was admitted on April 30, 2012 and was an active client at the time of the inspection. There was no documentation of an individual treatment and rehabilitation plan as of August 2, 2012.
The findings were confirmed during an interview with the facility director on August 2, 2012 at approximately 5:00 P.M.
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Plan of Correction
The Treatment Plan for Client #2 has been completed. Moving forward,the Program Supervisor will conduct an in-service training with all of the clinical staff to address treatment plans and the time frames of submission. Moving forward, the Director and/or Supervisor will monitor clinical charts daily to ensure that clinical staff are utilizing the information presented during the in-service training. Charts will be audited to assure all staff are meeting the guidelines of the policy and procedure manual, Treatment and Rehabilitation Services 709.52. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan.
The findings include:
On August 2, 2012, three client records requiring documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in one of two records reviewed, specifically, client record # 3.
Client # 3 was admitted on June 20, 2012. The individual treatment and rehabilitation plan was completed on June 21, 2012, but did not include documentation of the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan as of August 2, 2012.
The findings were confirmed during an interview with the facility director on August 2, 2012 at approximately 5:00 P.M.
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Plan of Correction
Moving forward, the Program Director and/or Program Supervisor will monitor clinical charts to ensure that the clinical staff document the type and frequency of rehabilitation services in the individual treatment plan according to the agency policy to meet state regulations. Clinical charts will be audited weekly by the management staff to ensure clinical staff are providing documentation of services as indicated. |
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.
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Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan.
The findings include:
On August 2, 2012, three client records were reviewed. The facility did not provide counseling services according to the individual treatment and rehabilitation plan in one of three client records reviewed, specifically, client record # 1.
Client # 1 was admitted on February 7, 2012 and was an active client at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 10, 2012 and indicated that the client would receive individual counseling sessions one time a week. There was no documentation of individual counseling for the week of February 12, 2012 and for the entire months of May, June, July 2012.
The findings were confirmed during an interview with the facility director on August 2, 2012 at approximately 5:00 P.M.
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Plan of Correction
Going forward, a procedure has been implemented that clinical staff will forward all individual counseling documentation for the day of service, prior to the end of their scheduled shift. Program Director and/or Program Supervisor will assure that all clinical documentation is completed and applied to the clinical chart. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document the record of services in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Intake Process/Paperwork," states: "All services rendered to a client shall be documented on the Record of Services form, which is maintained in the client record. The form should initially be completed with the intake paperwork. The Counselor or staff person scheduled to provide a service shall record the date a service is scheduled to be provided, the specific service and the initials of the staff responsible for the service. Documentation of this should be made promptly after the appointment is scheduled. The client's attendance status and the duration of the service shall be noted as soon as the disposition is known. A ROS is completed daily."
Also, the facility's policy titled: "Counseling Services," states: "All therapy services shall be noted on the Record of Services Provided form."
Three client records were reviewed on August 2, 2012. The facility did not document a record of service according to facility policy and procedures in three of three records reviewed, specifically, client records # 1, 2, and 3.
Client # 1 was admitted February 7, 2012. The individual treatment and rehabilitation plan for client # 1 was completed on February 10, 2012. Also, client # 1 received individual counseling sessions on the following dates: 2/26/12, 5/6/12, 2/10/12, 2/25/12, 3/2/12, 3/7/12, 3/16/12, 3/24/12, 3/30/12, 4/4/12, 4/12/12, 4/20/12, and 4/27/12. However, the only service the facility documented on the record of service was the client's intake service dated 2/7/12.
Client # 2 was admitted April 30, 2012. Client # 2 received group counseling sessions on the following dates: 5/3/12, 5/4/12, 5/9/12, 5/10/12, 5/11/12, 5/16/12, 5/18/12, 7/2/12, 7/13/12, 7/18/12, and 7/31/12. However, the only service the facility documented on the record of service was the client's intake service dated 4/30/12.
Client # 3 was admitted June 20, 2012. The individual treatment and rehabilitation plan was completed June 21, 2012. Also, client # 3 received individual counseling sessions on the following dates: 6/21/12, 6/28/12, 7/5/12, 7/12/12, 7/19/12. In addition, client # 3 received group counseling sessions on the following dates: 6/23/12 and 7/2/12. However, the only services the facility documented on the record of service was the client's intake service dated 6/20/12 and the client's individual treatment and rehabilitation plan dated 6/21/12.
The findings were confirmed during an interview with the facility director on August 2, 2012 at approximately 5:00 P.M.
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Plan of Correction
Corrections have been made specifically on client records #1,2, and 3, which include record of service and dates that were provided during the audit. Moving forward, the record of service will be utilized in all clinical charts and monitored by Program Director and/or Program Supervisor to ensure that all services are recorded according to Policy and Procedure, Record of Service 709.53. |