INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc.-Vantage 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 10, 2010.
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Plan of Correction
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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 the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Six personnel records were reviewed on May 5, 2010 to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 5 and 6.
Employee # 5 was hired on 1/11/10.
The training was due upon employment, the training had not documented until 5/14/10.
Employee # 6 was hired 4/12/10.
The training was due upon employment, the training had not documented until 5/14/10.
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Plan of Correction
As per licensing regulations, staff members will receive and the administrative coordinator will document fire extinguisher training upon staff employment for every new staff member within their first two days of employment.
Employee #5 and #6 had in fact recieved the fire extinguisher training and documentation was done and was sent to the reviewer the following day after our licensing visit.
Person Resonpsible: Administrative Coordinator
Person Responsible for the Monitoring: Program Director
Full compliance: 6/9/2010 |
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 on a review of inpatient client records and facility policies and procedures, the facility failed to document a physical examination in six of six outpatient client records as per facility policies and procedures.
The findings include:
On June 9, 2010, six inpatient client records were reviewed. Six of those records required documentation of a physical examination. The facility failed to document a physical examination in accordance with facility policy in five of six records reviewed.
Facility policy titled Physical Examination Laboratory Studies 709.51.b.5 states:
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.
1.Any physical examination not performed by the Gaudenzia physician will be
reviewed and signed off by him/her within 24 hours of client's admission to
the residential program.
2.Pennsylvania CBH clients are to have a completed physical within 72 hours -exceptions are holiday or weekend.
Client #1 was admitted on 2/24/2010, as of the date of the inspection, client record #1 did not have documentation of a physical examination.
Client #5 was admitted on 10/06/2009 and discharged on April 2, 2010, as of the date of the inspection, client record #5 did not have documentation of a physical examination.
Client #2 was admitted on 1/25/2010, the physical examination was not documented until 2/22/2010.
Client #3 was admitted on 1/21/2010, the physical examination was not documented until 2/19/2010.
Client #4 was admitted on 2/4/2010, the physical examination was not documented until 2/17/2010.
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Plan of Correction
As per Facility Policy titled Physical Examination Laboratory Studies 709.51.b.5 states: A client entering a Gaudenzia (residential) progam shall receive a complete physical examination by a qualified physician within 7 days of admission.
A meeting has been scheduled with our Medical Provider for July 15, 2010 to address and resolve this issue so that all clients who haven't had a complete physical within one month of admission will have a complete physical done within 7 days of entering Vantage.
To prevent this from recurring monthly meetings with our medical provider will be scheduled to ensure that all admissions have received a physical within the 7 day timeframe.
Person Responsible: Nurse
Person Responsible for Monitoring: Program Director
Full Compliance: 8/1/2010
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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 the review of client records, the facility failed to document comprehensive treatment plans after the completion of the clients' biopsychosocial histories and assessments in six out of six inpatient client records.
The findings include:
Facility policy titled Individual and rehab planning STANDARD: 709.52.a.1Stated:
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 clients problem list. The plan will be discussed with the client and changes made upon client request as appropriate.
Six client records were reviewed on June 9, 2010. Treatment plans were required in six client records. The treatment plans in client records #1, 2, 3, 4, 5, and 6 were completed before the clients' psychosocial evaluations were documented. Comprehensive treatment plans can not be developed until the client's psychosocial history and psychosocial evaluations are completed.
Client #1's comprehensive treatment plan was completed on 2/24/10 and their psychosocial evaluation was completed on 3/4/10.
Client #2's comprehensive treatment plan was completed on 1/25/10 and their psychosocial evaluation was completed on 1/29/10.
Client #3's comprehensive treatment plan was completed on 1/21/10 and their psychosocial evaluation was completed on 1/22/10.
Client #4's comprehensive treatment plan was completed on 2/4/10 and there was no documentation of a psychosocial evaluation in record #4.
Client #5's comprehensive treatment plan was completed on 10/06/09 and their psychosocial evaluation was completed on 10/13/09.
Client #6's comprehensive treatment plan was completed on 8/19/09 and their psychosocial evaluation was completed on 8/20/09.
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Plan of Correction
As per Facility policy titled Individual and rehab planning STANDARD: 709.52.a.1Stated:
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 clients problem list. The plan will be discussed with the client and changes made upon client request as appropriate.
This individualized treatment plan will be completed within the first five days of a client's admission.
Training was completed with the clinical staff in June 2010 on this procedure and a new monitoring system to ensure compliance with these regulations has been instituted as of June 10, 2010.
Person Responsible: Clinical Supervisor
Person Responsible for Monitoring: Program Director
Full compliance June 15, 2010
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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 on a review of the employee training records and the program's policies and procedures, the facility failed to timely document an individual training plan for each employee.
The findings include:
On May 4, 2010, six employee records were reviewed, four of which required a training plan for the 2010 training year. The program's policy states, "As training years run calendar, the training plan shall be ready for implementation effective Jan. 31st of each year " .
Employee # 1' s 2010 training plan was documented on April 28, 2010.
Employee # 2 ' s 2010 training plan was documented on February 18, 2010
Employee # 3 ' s 2010 training plan was not documented until February 2, 2010.
Employee # 4' s 2010 training plan was not documented until February 1, 2010.
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Plan of Correction
As per program policies and procedures, Vantage will document an individual training plan for each employee by January 31st of each year.
Person's responsible have been informed of this procedure and will be monitored to ensure compliance.
Person's responsible: Clinical Supervisor, Program Director
Person responsible for monitoring: Program Director
Full compliance 8/1/2010
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