INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 9, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Re-Entry 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:
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Plan of Correction
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on an observation during the physical plant inspection, it was determined that the project failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
An inspection of the residential portion of the facility was conducted on May 9, 2016 at approximately 1:00 pm.
Third Floor-
The bathroom next to bedroom #3 had caulking that was peeling away from the 1st shower closest to the bathroom door with black dirt in the cracks. In addition there was a crack with paint peeling away from the wall directly to the lower left of the 2nd shower that had black dirt, rust and what appeared to be mold in it.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Operations and the Director of Maintenance were informed and will make an assessment of all maintenance needs. Maintenance personnel will correct the deficiency and are in the process of assessing caulking needs. Shower stall mold and mildew will be removed. House Management Staff will supervise daily and weekly cleaning by residents. Monthly scheduled maintenance inspections will be conducted by the maintenance department under the supervision of the Director of Operations and Director of Maintenance to ensure the corrective action is implemented and the deficiency does not recur. The facility will be in full compliance by June 30, 2016. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to obtain an informed and voluntary consent to release in one of ten client records reviewed during the course of the annual licensing inspection on May 9, 2016.
Client #6 was admitted to treatment on September 28, 2015 and discharged on December 30, 2015. On a consent form dated 9/28/2015, the facility failed to document the name of the person, or organization to whom disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An in-service facilitated by the Program Director occurred on 5/10/16 to address Confidentiality. Ongoing training will be provided by the Gaudenzia Training Institute. To ensure compliance Program Director and Senior Counselor will audit charts bi-weekly to ensure documentation of the name of the person, or organization to which disclosure is being made. Additionally, charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by May 30, 2016. The Program Director will ensure compliance. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to document a complete client record on an individual, which includes information relative to the client's involvement with the project in three of ten client records reviewed during the course of the annual licensing inspection on May 9, 2016.
Client #6 was admitted to treatment on September 28, 2015 and discharged on December 30, 2015. The facility failed to document the client 's record of service and progress notes except for progress note 9/30/15.
Client # 8 was admitted to treatment on August 17, 2015 and discharged on November 16, 2015. The facility failed to document the client's record of service.
Client # 9 was admitted to treatment on October 7, 2015 and discharged on December 22, 2015. The facility failed to document the client's record of service and progress notes except for progress notes 10-9-15 and 10-18-15.
These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
Records of Service were placed in charts #6, #8, #9. To ensure compliance Director and Senior Counselor met with Clinical Staff 5/10/16 to review all aspects of a complete chart and how to properly document client progress and services provided in the Record of Service. Senior Counselor will audit charts weekly and ensure that all staff are clear that documentation must be timely and legible. Lastly, clinical staff will attend the revised Clinical Record Keeping and Current Standards Training. Program Director will oversee implementation of this plan of correction. The facility will be in full compliance by June 30, 2016. |