INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14-15, 2010 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 August 18, 2010.
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Plan of Correction
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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 a physical plant inspection and an interview with a client working in the kitchen, the facility failed to store all eating utensils in a clean enclosed area when not in use.
The findings include:
A physical plant inspection was conducted on June 15, 2010 at approximately 1:00 PM. The facility was required to store eating utensils in an enclosed area. The forks, knives and spoons were stored in uncovered utensil containers, on a utility cart, near the food service line in the kitchen.
An interview with a client working in the kitchen was conducted on June 15, 2010 at approximately 1:00 PM. The client confirmed that their practice was to store the eating utensils in the uncovered containers in the kitchen.
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Plan of Correction
On 8-2-10 the Program Director purchased utensil containers to place all eating utensils in. Spoons, knives and forks will be placed in this container and the container itself will then be placed in a clean enclosed area when not in use. The utensils will then be placed in utensil containers on the utility cart 10 minutes prior to meals being served. This procedure will be monitored by the facility cook manager and the Program Supervisor on a daily basis to ensure compliance to the standard. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection and an interview with the food manager, the facility failed to maintain cold food at or below 40 and frozen food at or below 0 findings include:
A physical plant inspection was conducted on June 15, 2010 at approximately 1:00 PM. The temperature of freezer in the basement was 2 and the temperature of the refrigerator in the kitchen was 48
These temperatures were rechecked at 2:00 PM, and the temperature of freezer in the basement was still 2 and the temperature of the refrigerator in the kitchen was 42 food manager stated that the facility shuts the freezers off between the hours of 2:00 PM and 3:00 PM while they stock them.
In addition there was meat in the freezer located on the first floor that was soft to the touch during the 1:00 PM physical plant inspection. This would have been 22 hours after it was put in the freezer from the day before if the facility had completed stocking the freezer at 3:00 PM.
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Plan of Correction
Beginning 8-1-2020, all refrigerator and freezer temperatures will be checked at the beginning and end of each shift. This will be done by the desigignated staff on duty and the cook manager. These temperatures will be documented and reviewed by the Program Supervisor on a daily basis for a period of three months. If there are any problems with refrigerator or freezer temperatures at the beginning or end of a shift, the problem will immediately be reported to the Program Supervisor so a service technician can be contacted within a twenty four hour period. Any contact with a service technician for repairs will also be documented. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel training records and an interview with the Training Manager, the facility failed to document that all personnel are trained to perform assigned task during emergencies in one of seven personnel records reviewed.
The findings include:
Seven personnel training records were reviewed on May 7, 2010. All seven records required documentation that emergency training was provided to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The facility did not document that emergency training was provided for employee #5 until 20 days following employment.
Personnel #5 was hired on 3/15/10, but the training certificate for emergency training was dated 4/5/10.
Facility Policy titled Policy for Physical Plant Stated:
First staff person to discover fire (or disaster)
IR Rescue: endangered persons.
2.A Alarm: alert fire department
3.C Confine: close doors, windows, etc.
disconnect appliances; close gas jets, etc.
4.E Evacuate: as prudent and indicated.
5.S Surveillance: is everyone accounted for?
(Patient registry should be removed on first indication of
problem to facilitate accountability of patients.)
Evacuation Procedures
Upon notification of an impending or actual emergency or disaster either by alarm or verbally, staff on duty, or the person in charge will have all occupants vacate the premises via predetermined and posted routes and assemble in the parking lot beyond the front of the building.
Staff on duty or the person in charge will insure occupants have been evacuated. A count will be taken at the assembly area to count for the whereabouts of all persons. The staff on duty will also insure that windows and doors are secure when safe to do so. If it is determined that the facility cannot be re-entered, the person in charge will make arrangements to transport and house the people at other Gaudenzia facilities and/or alternative appropriate facilities.
Evacuation of clients who are or appear to be impaired
In circumstances where a client is deemed to be under the influence of alcohol or other drugs, the client will be escorted (assisted) by either staff or the designated house manager outside the building. Once outside the building and safe, the process will be initiated to transfer the client to a medically monitored detoxification program.
An interview with the Training Manager on May 7, 2010 confirmed that personnel #5 was not trained to perform assigned task during emergencies until 20 days following employment at the facility.
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Plan of Correction
On 8-1-2010, all staff training records were reviewed by the Administrative Coordinator and the Program Supervisor to ensure that all current staff members meet licensing regulations. Beginning 8-1-2020, all new staff will recieve emergency training within one week of being hired. All emergency training registrations will be supervised by the Administrative Coordinator in conjunction with the Program Supervisor. Beginning 8-1-2010, the Program Director will review all new hire trainings with one week of their being hired. Beginning 8-1-2010 all staff training will be review by the Administrative Coordinator, Program Supervisor and Program Director on a monthly basis. |
709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on a review of the client handbook and a review of client records, the facility failed to develop policies and procedures on client rights that included the client ' s right to appeal a decision limiting access to his records to the project director and demonstrate efforts towards informing clients of their rights in eleven of eleven records reviewed.
The findings include:
The client handbook and eleven client records were reviewed on June 15-15, 2010.
The listing of client rights in the client handbook did not include the right of the client to appeal a decision limiting access to his records to the project director. The client rights sign off forms in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11 also did not include information on the right of a client to appeal a decision limiting access to his record to the project director.
The client rights did not include:
The client has the right to appeal a decision limiting access to his records to the project director.
An interview with the facility director was conducted on June 15, 2010. The facility director confirmed that the client handbook and the client rights sign-off forms did not include information on the right of the client to appeal a decision limiting access to his record to the project director.
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Plan of Correction
On 8-5-2010 both the Concept 90 handbook that includes client's rights as well as the signed copy of client's rights that is filed in the client's chart was ammended to include the right to appeal a decision limiting access to his/her records to the Project Director. All previous copies of client handbooks have been retrieved from the clients and destroyed and new handbooks have been distributed. The Administrative Coordinator will monitor all new admissions and signing of client's rights and the Program Supervisor will monitor the distribution of client handbooks. This will occur on an ongoing basis as new admissions arrive to Concept 90. |
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 the review of client records, the facility failed to document an individual treatment and rehabilitation plan to include type and frequency of treatment and rehabilitation services in five of eleven client records.
The findings include:
Eleven client records were reviewed on June 14-15, 2010. The facility did not document a treatment and rehabilitation plan to include type and frequency of treatment services, as per facility policy, in client records # 1, 3, 4, 5 and 8.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. "
In client record #1, the treatment plan documented on 3/25/10 did not include type and frequency of treatment and rehabilitation services.
In client record #3, the treatment plan documented on 2/23/10 did not include type and frequency of treatment and rehabilitation services.
In client record #4, the treatment plan documented on 3/23/10 did not include type and frequency of treatment and rehabilitation services.
In client record #5, the treatment plan documented on 1/21/10 did not include type and frequency of treatment and rehabilitation services.
In client record #8, the treatment plan documented on 1/21/10 did not include type and frequency of treatment and rehabilitation services.
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Plan of Correction
On 8-2-2010 a clinical training was held at Concept 90. The training involved all clinical staff and was facilitated by the Concept 90 Program Supervisor. The training was monitored by the Program Director. The training included treatment planning and documentation of type and frequency of rehabilitation services. Included in all treatment plans wil be a statement of the type of treatment such (individual, group, family), and frequency, (daily, 2x per week, or ongoing, etc) of services that the client will be involved. To ensure compliance with this standard, all treatment plans will be audited by the Program Supervisor for a period of three months on a weekly basis. If after three months type and frequency has been included consistantly in all plans, the Program Supervisor will audit treatment plans on a monthly basis. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to document a treatment plan update in ten of ten client records.
The findings include:
Ten client records requiring documentation of treatment plan updates were reviewed on June 14-15, 2010. The facility did not document a treatment plan update, as per facility policy, in ten of ten client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
The facility ' s policy titled " Treatment Plan Reviews " states:
The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted.
In client record #1, the treatment plan updates documented on 4/21/10 and 5/21/10 were incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #2, the treatment plan update documented on 5/22/10 was incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #3, the treatment plan updates documented on 3/15/10, 4/15/10 and 5/10/10 were incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #4, the treatment plan updates documented on 4/23/10 and 5/24/10 were incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #5, the treatment plan update documented on 2/21/10 was incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #6, the treatment plan update documented on 4/19/10 was incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #7, the treatment plan update documented on 5/19/10 was incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #8, the treatment plan updates documented on 2/19/10 and 3/18/10 were incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #9, the treatment plan updates documented on 2/4/10 and 3/4/10 were incomplete. The updates did not include an assessment of progress as required by facility policy.
In client record #10, the treatment plan update documented on 1/30/10 was incomplete. The updates did not include an assessment of progress as required by facility policy.
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Plan of Correction
On 8-2-2010 a clinical training was held at Concept 90. The training involved all clinical staff and was facilitated by the Concept 90 Program Supervisor. The training was monitored by the Program Director. Included in this clinical training was treatment updates. As per facility policy all treatment updates will be completed within thirty days after the date of the original individual treatment plan and every thirty days thereafter. These updates will include but not be limited to, an assessment of the client's progress on the goals identified on the treatment plan as well as a specific indication of how each specific goal has been impacted. The clinician will write an assessment on the progress of each prior goal and how that goal has impacted the client. To ensure compliance with this standard the Program Supervisor will audit all treatment plans for completeness, specifically treatment plan updates on a weekly basis for a period of three months. If treatment plan updates are corrected consistantly for a period of three months the Program Supervisor will then audit treatment plans on a monthly basis. |
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 the review of client records, the facility failed to document progress notes in eleven of eleven client records.
The findings include:
Eleven client records were reviewed on June 14-15, 2010 for group progress notes. The facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11.
Client #1: A review of group session progress notes for group sessions held between March 22, 2010 and June 15, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #2: A review of group session progress notes for group sessions held between April 21, 2010 and June 15, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #3: A review of group session progress notes for group sessions held between February 16, 2010 and June 15, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #4: A review of group session progress notes for group sessions held between March 23, 2010 and June 15, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #5: A review of group session progress notes for group sessions held between January 19, 2010 and June 15, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #6: A review of group session progress notes for group sessions held between March 19, 2010 and June 15, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #7: A review of group session progress notes for group sessions held between April 19, 2010 and June 15, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #8: A review of group session progress notes for group sessions held between January 19, 2010 and April 19, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #9: A review of group session progress notes for group sessions held between January 4, 2010 and March 18, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #10: A review of group session progress notes for group sessions held between December 30, 2009 and March 30, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual's response or participation, as per facility policy, for any of the group progress notes.
Client #11: A review of group session progress notes for group sessions held between January 11, 2010 and January 26, 2010 revealed that the facility did not document group progress notes to include a comment relative to each individual ' s response or participation, as per facility policy, for any of the group progress notes.
The facility ' s policy titled " CLIENT COUNSELING LOGS / PROGRESS NOTES " states:
" 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. "
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Plan of Correction
On 8-2-2010 a clinical training was held at Concept 90. The training involved all clinical staff and was facilitated by the Concept 90 Program Supervisor. The training was monitored by the Program Director. Included in the training was training specific to the proper documentation of progress notes. A progress note will be written for each group. All progress notes will include a comment relative to each clients response or participation in the group session. Compliance to this standard will be monitored by the Program Supervisor. The Program Supervisor will audit all group notes for a period of three months for compliance. If group notes consistantly meet the standard after the three month audit the Program Supervisor wil then include progress notes in the monthly chart review. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the facility ' s Monthly Statistical Report, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum client capacity.
The findings include:
The Monthly Statistical Report was reviewed on June 15, 2010. The facility ' s authorized maximum capacity for Inpatient Non-Hospital clients is 42. In 2010, the Monthly Statistical Reports for January, February, March, April, May and June, indicate days where the number of Inpatient Non-Hospital clients exceeds the authorized maximum capacity of 42.
The capacity exceeded 42 clients on January 4(45), 11(43), 19(44), 20(44), 21(43), 22(44), 23(44), 24(44), 25(43), 28(43), 29(43), 30(43) and 31(43).
The capacity exceeded 42 clients on February 5(43), 6(43), 7(44), 8(43), 9(43), 10(43), 11(43), 12(43), 13(43), 14(43), 16(43) and 17(44).
The capacity exceeded 42 clients on March 1(43), 2(43), 4(43), 5(43), 6(43), 7(43), 8(44), 9(43), 15(43), 17(43), 19(44), 20(44), 21(44), 22(43), 29(44), 30(44) and 31(43).
The capacity exceeded 42 clients on April 1(43), 2(43), 3(43), 4(43), 5(44), 6(44), 8(44), 9(43), 10(43), 11(43), 12(43), 13(43), 14(43), 26(43), 27(43), 28(43) and 29(43).
The capacity exceeded 42 clients on May, 3(43), 14(43), 15(43), 16(43), 17(44), 18(44), 19(44), 20(44), 21(44), 22(44), 23(44), 24(45), 25(44), 26(44), 27(43), 28(43), 29(43), 30(43), 31(44).
The capacity exceeded 42 clients on June 1(43) and 2(43).
An interview with the facility director was conducted on June 15, 2010. The facility director confirmed that the monthly statistical reports were correct and that they had exceeded the authorized maximum client capacity and failed to notify the Department of the increase. When asked if the facility had extra beds onsite, the facility director said that they did not but that he has access to extra beds. He also stated that he calls his supervisor and gets approval to set up the extra beds when the facility is over capacity.
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Plan of Correction
The facility will refrain from exceeding the authorized maximum capacity (42). Additionally, the facility will notify the Department within 90 days of any occurrence in the change of the authorized maximum capacity. To ensure compliance to this standard the facility will refrain from setting up or gaining access to any extra beds. This will be monitored by the Program Director the Division Director, and the Regional Director. In addition, the Program Director will work in conjunction with the Intake Specialist to ensure that the daily census does not exceed forty two (42). An administrative meeting will be held weekly, involving the Administrative Coordinator, Intake Specialist, and Program Director to review the daily census. This meeting will occur on an ongoing basis and the results of the meeting will be sent to the Division and Regional Directors. |