INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 13, 2015 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of the facility's May 2015 work schedule and staff CPR and first aid cards provided by the facility, the facility failed to provide sufficient CPR coverage.
The findings include:
On May 13, 2015, copies of the staff CPR and First Aid cards and the May 2015 work schedule as provided by the facility were reviewed. The facility works on a 24 hours/7 days a week work schedule. The current CPR certifications cards expired on May 3, 2015.
The facility failed to provide CPR coverage on the following days and shifts:
May 4, 2015 from 8 AM to 4 PM
May 5, 2015 from 8 AM to 4 PM & 4 PM to 12 AM
May 6, 2015 from 8 AM to 4 PM
May 7, 2015 from 4 PM to 12 AM
May 8, 2015 from 8 AM to 4 PM
May 9, 2015 from 8 PM to 8 AM
May 10-11, 2015 from 8 AM to 4 PM, from 4 PM to 12 AM, and from 12 AM to 8 AM
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has ensured that all Staff has updated certification for CPR/First Aid Training on every shift as outlined in Program Policy. Program Director will also follow up every three months to ensure that all Staff are in compliance. |
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 a physical plant inspection, the facility failed to keep the grounds clean, safe, and sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The findings include:
A physical plant inspection was conducted on May 13, 2015. The facility failed to keep the grounds safe and in good repair at all times.
1. The entire bathroom on the third floor had chipped and cracked paint.
2. The bathtub on the second floor in bedroom # 4 had mold and mildew on the wall.
3. Bathroom # 5 had a large cracked sink around the sink.
4. Bathroom # 8 had a large exhaust fan dangling from the ceiling.
The 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 made an assessment of all painting and maintenance needs. A painter was hired to correct the deficiency and is in the process of painting the facility to address the marred walls, chipped and cracked paint. Bath tub mold and mildew on the walls has been removed. The cracked sink has been replaced and the exhaust fan in #8 has been corrected. Regularly 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. |
705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on a physical plant inspection, the facility failed to provide toilet paper at each toilet at all times, an operable soap dispenser and either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
A physical plant inspection was conducted on May 13, 2015. The facility failed to provide toilet paper at each toilet at all times, an operable soap dispenser and either individual paper towels or a mechanical dryer in each bathroom, specifically the third floor bathroom off of the main steps.
The 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 made an assessment of all painting and maintenance needs. Maintenance personnel installed operable wall mounted soap dispensers and paper towel dispensers in all bathrooms. Two rolls of toilet paper have been placed at all toilets and regular inspections will be made to identify the need for replacements. Regularly 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 was implemented and the deficiency does not recur. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a review of the facility's active and discharged client list, the facility failed to secure client records within a locked storage container.
The findings include:
On May 13, 2015, the active and discharged client lists were reviewed and random samples of client records were selected for review. Seven active client records and three discharge client records were selected, # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. The facility failed to provide client record, # 5 for review.
Client # 5 was admitted to the facility on March 13, 2015, and was still an active client at the time of inspection. Client # 5's record was requested at the beginning of the inspection. The facility failed to provide client # 5's record at the completion of the inspection on May 13, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client record # 5 was located and returned to the locked storage container. The facility has secured all client records (open and closed) within locked storage containers. An in-service facilitated by the Program Director occurred on 6/24/15 to address Confidentiality as it pertained to client records. Program Director and Senior Counselor will monitor chart storage closely to ensure compliance. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document consent to treatment in two of nine records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015, for documentation of consent to treatment. The facility failed to document consent to treatment in two of nine client records, client record # 4 and 9.
Client # 4 was admitted to the facility on March 12, 2015, and was still an active client at the time of inspection. The facility failed to document a consent to treatment for client # 4 as of the date of the licensing inspection.
Client # 9 was admitted to the facility on February 24, 2015 and discharged on March 31, 2015. The facility failed to document a consent to treatment for client #9 as of the date of the licensing inspection.
The 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 6/24/15 to address documentation of Consent to treatment. Ongoing training will be provided by the Gaudenzia Training Institute. Program Director will monitor charts closely to ensure compliance. Additionally, charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by June 31, 2015. The Program Director will ensure compliance. |
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 client records, the facility failed to document a physical examination in two of nine records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015, for documentation of a physical examination. The facility failed to document a physical examination in two of nine client records, # 4 and 7.
Client # 4 was admitted to the facility on March 12, 2015, and was still an active client at the time of inspection. The facility failed to document a physical examination as of the date of the licensing inspection.
Client # 7 was admitted to the facility on February 26, 2015, and was still an active client at the time of inspection. The facility failed to document a physical examination as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An in-service training was scheduled to instruct Staff on Physical Examination policy and protocol. In the event a client is admitted without a verifiable physical examination, the chart will be flagged and immediately delivered to the Program Director to ensure that this client is a priority for referral to a medical facility within one week for a physical examination. To ensure this deficiency does not reoccur supervision staff will monitor compliance for physical examination documents to ensure compliance. An in-service training was facilitated on 6/24/15 to instruct Staff on Physical Examination policy. All Clients will have verifiable physical examinations within one month prior to admission or a physical examination will be performed during the first week of admission. Referring agency will be informed physicals must be within thirty days of admission to Re-Entry Program. In the event a client is admitted without a verifiable physical examination within one month, a physical examination will be performed by Abbotsford ? Falls Family Practice, 4700 Wissahickon Avenue, Suite #119, Philadelphia, PA 19144 within one week. Senior Counselor will monitor compliance for physical examination documents during client admission process, counselor supervision, and chart auditing process. Senior Counselor will report findings for three months in CQI. Program Director will oversee this Plan of Correction. (6/24/15) |
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 client records, the facility failed to document a psychosocial evaluation in two of nine records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015, for documentation of a psychosocial evaluation. The facility failed to document a psychosocial evaluation in two of nine client records, # 2 and 8.
Client # 2 was admitted to the facility on February 5, 2015. The facility failed to document a psychosocial evaluation as of the date of the licensing inspection.
Client # 8 was admitted to the facility on December 17, 2014 and discharged on March 11, 2015. The facility failed to document a psychosocial evaluation as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
Client #8 has discharged from the program. The necessary corrections have been made in Client chart #2. On 6/24/15 the Program Director addressed documentation of psychosocial evaluations in accordance with facility policy. Psychosocial evaluation coping mechanisms, attitude and receptivity towards treatment and evaluation of the client's support systems were addressed to ensure clinicians are able to address client strengths, needs, ability, preference, and resilience. To ensure this deficiency does not repeat, charts will be monitored by supervision staff. The facility will be in full compliance by June 24, 2015. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in eight of nine records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015, for documentation of a preliminary treatment and rehabilitation plan. The facility failed to document a preliminary treatment plan in eight of nine client records, # 1, 2, 4, 6, 7, 8 and 10.
Client # 1 was admitted to the facility on February 24, 2015. The facility failed to document a preliminary treatment plan during intake and admission for client # 1 as of the date of the licensing inspection.
Client # 2 was admitted to the facility on February 5, 2015. The facility failed to document a preliminary treatment plan during intake and admission for client # 2 as of the date of the licensing inspection.
Client # 4 was admitted to the facility on March 12, 2015. The facility failed to document a preliminary treatment plan during intake and admission for client # 4 as of the date of the licensing inspection.
Client # 6 was admitted to the facility on February 18, 2015. The facility failed to document a preliminary treatment plan during intake and admission for client # 6 as of the date of the licensing inspection.
Client # 7 was admitted to the facility on February 26, 2015. The facility failed to document a preliminary treatment plan during intake and admission for client # 7 as of the date of the licensing inspection.
Client # 8 was admitted to the facility on December 17, 2014. The facility failed to document a preliminary treatment plan during intake and admission for client # 8 as of the date of the licensing inspection.
Client # 10 was admitted to the facility on January 9, 2015. The facility failed to document a preliminary treatment plan during intake and admission for client # 10 as of the date of the licensing inspection.
The 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 6/24/15 to address Preliminary Treatment plans. 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 preliminary treatment plans are done. Additionally, charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by June 31, 2015. The Program Director will ensure compliance. |
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 facility failed to document an individual treatment and rehabilitation plan and/or failed to document type and frequency on the treatment plan in five of nine records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015, for documentation of an individualized treatment and rehabilitation plan. The facility failed to document an individual treatment plan and/or failed to document type and frequency on the treatment plan in five of nine client records, #4, 6, 7, 8 and 10.
Client # 4 was admitted to the facility on March 12, 2015, and was still an active client at the time of inspection. The facility failed to document an individualized treatment plan for client #4 at the time of licensing inspection.
Client # 6 was admitted to the facility on February 18, 2015, and was still an active client at the time of inspection. The facility documented the individual treatment plan on February 24, 2015; however, the plan did not include the type and frequency of treatment services.
Client # 7 was admitted to the facility on February 26, 2015, and was still an active client at the time of inspection. The facility documented the individual treatment plan on March 11, 2015; however, the plan did not include the type and frequency of treatment services.
Client # 8 was admitted to the facility on December 17, 2014 and discharged on March 11, 2015. The facility failed to document an individualized treatment plan as of the date of the client's discharge date.
Client # 10 was admitted to the facility on January 9, 2015 and discharged on April 10, 2015. The facility failed to document an individualized treatment plan as of the date of the client's discharge date.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
Corrections were made in client records #4, #6, #7; records #8 and #10 were closed charts. All Treatment Plans will be tracked every three months at monthly CQI Meetings in the areas of Timeliness, Completeness and Effectiveness. Treatment and Rehabilitation Services and Treatment Plans will be revised to reflect the correct Treatment milieu and Program Manual Requirements. An In-Service Training will be facilitated on 6/24/15 to discuss the importance of type and frequency on Treatment Plans.
Program Director will review monthly all Treatment Plans to ensure that criteria for Treatment Planning is met.
All Clinical Staff will attend additional In-Service Trainings which will address the areas of Type and Frequency of Treatment and Rehabilitation Services.
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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 a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 30 days in three of five records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015. Five client records were required to have treatment and rehabilitation plans updated at least every 30 days. The facility failed to review and update treatment plans at least every 30 days in three of five client records, #1, 2 and 3.
Client # 1 was admitted to the facility on February 24, 2015, and was still an active client at the time of inspection. The facility completed the individualized treatment plan on March 3, 2015. The treatment plan update was due at least every 30 days or by April 3, 2015.
Client # 2 was admitted to the facility on February 5, 2015, and was still an active client at the time of inspection. The facility completed the individualized treatment plan on February 11, 2015. The treatment plan update was due at least every 30 days or by March 11, 2015.
Client # 3 was admitted to the facility on February 20, 2015, and was still an active client at the time of inspection. The facility completed the individualized treatment plan on February 20, 2015 and a treatment plan update on March 20, 2015; however, the facility failed to update the treatment plan by April 20, 2015.
The findings were reviewed with facility staff during the licensing process
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Plan of Correction
The necessary corrections have been made in Client charts #1, #2, #3. An in-service facilitated by the Program Director occurred on 6/24/15 to address Treatment and rehabilitation service TX plan Update. Ongoing training will be provided by the Gaudenzia Training Institute. Program Director will monitor charts closely to ensure compliance. Additionally, charts will be monitored through our Continues Quality Improvement Program. 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
Based on a review of client records, the facility failed to document a complete client record in eight of nine client records reviewed.
The findings include:
Nine client records were reviewed on May 13, 2015. The facility failed to document a complete client record that included a record of services provided, and/or that work done by the client is an integral part of the treatment and rehabilitation plan in client records # 1, 2, 3, 6, 7, 8, 9 and 10.
Client # 1 was admitted to the facility on February 24, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided and documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 2 was admitted to the facility on February 5, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided, and documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 3 was admitted to the facility on February 20, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided, and documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 6 was admitted to the facility on February 18, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 7 was admitted to the facility on February 26, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 8 was admitted to the facility on December 17, 2014 and discharged on March 11, 2015. The facility failed to document a complete client record which included a record of services provided.
Client # 9 was admitted to the facility on February 24, 2015 and discharged on March 31, 2015. The facility failed to document a complete client record which included documentation that work done by client was an integral part of their treatment and rehabilitation plan.
Client # 10 was admitted to the facility on January 9, 2015 and discharged on April 10, 2015. The facility failed to document a complete client record which included a record of services provided.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Records of Service were placed in charts #1, #2, #3, #6, #7, #8, #9, #10. Director and Senior Counselor met with Clinical Staff 6/24/15 to review all aspects of a complete chart and how to properly document the Record of Services provided. Senior Counselor will ensure that all staff is clear that all documentation must be timely and legible. Lastly, any clinical staffs who have not yet attended the revised Clinical Record Keeping and Current Standards Training, must attended the next scheduled training event. Program Director will oversee this to ensure compliance with this plan of correction. |
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 physical plant inspection, the facility failed to comply with the maximum approved capacity and failed to notify the Department within 90 days of a change in the authorized maximum capacity.
The findings include:
A physical plant inspection was conducted on May 13, 2015.
The facility is licensed by the Division for a maximum client capacity of 23 inpatient non-hospital drug-free beds. The facility exceeded the licensed maximum capacity as there were 24 beds in the facility at the time of inspection.
Based on observation, bedroom # 3 on the third floor had an additional bed set-up in the room.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Bed was dismantled. Bed was in place temporarily due to maintenance work in another bedroom. Program Director will contact BDAP in advance to request permission to install temporary bed in the future. |