INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 16, 2011 licensure renewal inspection. The follow-up inspection was conducted on November 30, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based on observation, and a physical plant inspection, the facility failed to comply with applicable Federal, State and local laws and ordinances.
The findings include:
The city of Philadelphia uses the International Building Code which includes the National Electrical Code (N.E.C.)
The N.E.C. requires that the wiring be installed in a workman like manner and that it be secured within 12 inches of a junction box/electrical box or panel box and a minimum of every four and a half feet thereafter. In addition, armored cable is to be secured to each joist when exposed and it is not to be supported off of piping or ductwork.
A physical plant inspection was conducted on November 30, 2011 from approximately 10:14 A.M. to 10:31 A.M. and from approximately 12:12 P.M. to 12:15 P.M.
The facility failed to ensure that the electrical wiring located in the basement was installed and secured in accordance with the National Electrical Code (N.E.C.).
Exposed electrical wires were observed throughout the basement area which is used by residents and staff for food and clothing storage, recreation, and laundry.
The facility has secured the majority of the wires within 12 inches of panel box and every four and a half feet since the last inspection on May 16, 2011. However, not all the wires have been secured within 12 inches of the panel box.
The findings were confirmed during an ongoing dialogue with the house manager on November 30, 2011 from approximately 10:14 A.M. to 10:31 A.M. Also, the findings were confirmed during an ongoing dialogue with the lead counselor on November 30, 2011 from approximately 12:12 P.M. to 12:15 P.M.
This is a repeat citation. The facility was cited on May 16, 2011 for noncompliance with this standard.
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Plan of Correction
The Director of Operations was informed of the electrical wiring deficiencies identified during the on sight inspection conducted November 30, 2011. An assessment was made to determine how to proceed with correcting the deficiency. The Director Of Operations will ensure that the facility meets N.E.C. requirements. A box was installed to cover exposed wires on December 7, 2011. |
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 accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Physical Examination Laboratory Studies," 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.
2.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.
3.Pennsylvania CBH clients are to have a completed physical within 72 hours-exceptions
are holiday or weedend.
Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client."
On November 30, 2011, seven records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination according to their policy and procedures in six of seven records reviewed, specifically, client records # 1, 2, 3, 5, 6, and 7.
Client # 1, a CBH client, was admitted October 3, 2011. The physical examination was completed on September 19, 2011, but did not include the client's vital signs, a review of organ systems, and general appearance.
Client # 2, a CBH client, was admitted September 7, 2011. The physical examination was due within 72 hours of admission with the exceptions of holidays or weekends by September 12, 2011. However, the physical examination was not completed until September 28, 2011.
Client # 3, a CBH client, was admitted October 11, 2011. The physical examination was due within 72 hours of admission with the exceptions of holidays or weekends by October 14, 2011. However, the physical examination was not completed until October 15, 2011. Also, the physical examination did not include the client's vital signs, a review of organ systems, and general appearance.
Client # 5, a CBH client, was admitted October 31, 2011. One physical examination was completed on September 7, 2011 and another physical examination was completed on October 12, 2011. However, both of the physical examinations did not include the client's vital signs, a review of organ systems, and general appearance.
Client # 6, a CBH client, was admitted November 7, 2011. The physical examination was to be completed no longer than one month prior to admission. However, the physical examination was completed on August 17, 2011, more than one month prior to admission.
Client # 7, a CCBH client, was admitted September 29, 2011. The physical examination was to be completed no longer than one month prior to admission. However, the physical examination was completed on August 16, 2011, more than one month prior to admission. Also, the physical examination did not include the client's vital signs, a review of organ systems, and general appearance.
The findings were confirmed during an ongoing dialogue with the facility director on November 30, 2011 from approximately 3:15 P.M. to 4:00 P.M.
This is a repeat citation. The facility was cited on May 16, 2011; December 2, 2010; and June 10, 2010 for noncompliance with this standard.
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Plan of Correction
An in-service training is 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 recur supervision staff will monitor compliance for physical examination documents weekly and progressive corrective actions will be instituted by the Program Director to ensure compliance. |
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.
Also, based on a review of client records, the facility failed to document a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Procedure For Intake Documentation Of Histories," states:
"Psychosocial Assessment:Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weakness, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client's strengths, abilities and preferences (SNAP). The assessment shall be submitted promptly (not to exceed 3-5 treatment days after the client's admission to the program) to the Clinical Supervisor for review and signature for residential and within 3 individual sessions for outpatient."
On November 30, 2011, seven client records requiring documentation of psychosocial evaluations were reviewed. The facility did not document a psychosocial evaluation in one of seven records reviewed, specifically, client record # 5. Also, the facility did not document a psychosocial evaluation according to their policy and procedures in six of seven records reviewed, specifically, client records # 1, 2, 3, 4, 6, and 7.
Client # 1 was admitted October 3, 2011. The psychosocial evaluation was completed on October 5, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 2 was admitted September 7, 2011. The psychosocial evaluation was completed on September 8, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 3 was admitted October 11, 2011. The psychosocial evaluation was completed on October 13, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 4 was admitted September 27, 2011. The psychosocial evaluation was completed on September 29, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 5 was admitted October 31, 2011. The psychosocial evaluation was due by the fifth treatment day on November 5, 2011; however, client record # 5 did not include documentation of a psychosocial evaluation as of November 30, 2011.
Client # 6 was admitted November 7, 2011. The psychosocial evaluation was completed on November 9, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
Client # 7 was admitted September 29, 2011. The psychosocial evaluation was completed on September 30, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and coping mechanisms.
The findings were confirmed during an ongoing dialogue with the facility director on November 30, 2011 from approximately 3:15 P.M. to 4:00 P.M.
This is a repeat citation. The facility was cited on May 16, 2011 for noncompliance with this standard.
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Plan of Correction
Clients #1, #2, #3, and #7 have discharged from the program. The necessary corrections have been made in Client charts #4, #5 and #6. On Friday, December 9, 2011 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 will be addressed to ensure clinicians are able to address client strengths, needs, ability, preference, and resilience. CQI committee will address revising the Psychosocial Evaluation Form format. To ensure this deficiency does not repeat, charts will be monitored by supervision staff and progressive corrective actions will be instituted by the Program Director to ensure compliance. The facility will be in full compliance by December 31, 2011. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan.
The findings include:
On November 30, 2011, six client records requiring documentation of short-term and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in five of six records reviewed, specifically, client records # 1, 2, 3, 6, and 7.
Client # 1 was admitted October 3, 2011. The individual treatment and rehabilitation plan was completed on October 5, 2011, but it did not include documentation of the long-term goals for treatment as of November 30, 2011.
Client # 2 was admitted September 7, 2011. The individual treatment and rehabilitation plan was completed on September 8, 2011, but it did not include documentation of the long-term goals for treatment as of November 30, 2011.
Client # 3 was admitted October 11, 2011. The individual treatment and rehabilitation plan was completed on October 11, 2011, but it did not include documentation of the long-term goals for treatment as of November 30, 2011.
Client # 6 was admitted November 7, 2011. The individual treatment and rehabilitation plan was completed on November 9, 2011, but it did not include documentation of the long-term goals for treatment as of November 30, 2011.
Client # 7 was admitted September 29, 2011. The individual treatment and rehabilitation plan was completed on September 30, 2011, but it did not include documentation of the long-term goals for treatment as of November 30, 2011.
The findings were confirmed during an ongoing dialogue with the facility director on November 30, 2011 from approximately 3:15 P.M. to 4:00 P.M.
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Plan of Correction
Clients #1, #2, #3, and #7 have discharged from the program. The necessary corrections have been made in Client chart #6. An in-service facilitated by the Program Director took place on 12/9/11 to address Treatment and rehabilitation service Individual TX plan, (long term goals). Ongoing training will be provided by the Gaudenzia Training Institute. Program Director will monitor charts closely to ensure compliance. Corrective actions will be instituted for non-compliance. Additionally, charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by December 31, 2011. The Program Director will ensure compliance. |
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 document a treatment and rehabilitation plan update in accordance with their policy and procedures.
Also, based on a review of client records, the facility failed to document a treatment and
rehabilitation plan update.
The findings include:
The facility's policy titled: "Treatment Plan Reviews," stated:
"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. Any goal or action step
additions, revisions and deletions shall also be reflected. Goal and action step changes shall
also be reflected on the treatment plan. The update shall be signed by the Counselor and
submitted to the Clinical Supervisor for review and signature."
On November 30, 2011, five client records requiring documentation of a treatment and rehabilitation plan update were reviewed. The facility did not document a treatment and rehabilitation plan update according to their policy and procedures in three of five records reviewed, specifically, client records # 1, 4, and 7. The facility also did not document a treatment and rehabilitation plan update in two of five records reviewed, specifically, client records # 2 and 3.
Client # 1 was admitted October 3, 2011 and the individual treatment and rehabilitation plan was completed on October 5, 2011. The treatment plan update was due November 4, 2011; however, the treatment plan update was not completed until November 5, 2011.
Client # 2 was admitted September 7, 2011 and the individual treatment and rehabilitation plan was completed on September 8, 2011. The treatment plan update was due November 8, 2011; however, client record # 2 did not include documentation of a treatment plan update as of November 30, 2011.
Client # 3 was admitted October 11, 2011 and the individual treatment and rehabilitation plan was completed on October 11, 2011. The treatment plan update was due November 10, 2011; however, client record # 3 did not include documentation of a treatment plan update as of November 30, 2011.
Client # 4 was admitted September 27, 2011 and the individual treatment and rehabilitation plan was completed on September 30, 2011. The treatment plan update was due October 30, 2011; however, the treatment plan update was not completed until October 31, 2011.
Client # 7 was admitted September 29, 2011 and the individual treatment and rehabilitation plan was completed on September 30, 2011. The treatment plan update was due October 30, 2011; however, the treatment plan update was not completed until October 31, 2011.
The findings were confirmed during an ongoing dialogue with the facility director on November 30, 2011 from approximately 3:15 P.M. to 4:00 P.M.
This is a repeat citation. The facility was cited on May 16, 2011; December 2, 2010; and June 10, 2010 for noncompliance with this standard.
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Plan of Correction
Clients #1, #2, #3, and #7 have discharged from the program. The necessary corrections have been made in Client chart #4. An in-service facilitated by the Program Director occurred on 12/9/11 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. Corrective actions will be instituted for non-compliance. Additionally, charts will be monitored through our Continues Quality Improvement Program. The facility will be in full compliance by December 31, 2011. The Program Director will ensure compliance. |
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 are provided according to the individual treatment and rehabilitation plan.
The findings include:
On November 30, 2011, six client records requiring documentation that counseling services are provided according to the individual treatment and rehabilitation plan were reviewed. The facility did not provide counseling services according to the individual treatment and rehabilitation plan in six of seven records reviewed, specifically, client records # 1, 2, 3, 4, 6, and 7.
Client # 1 was admitted October 3, 2011. The individual treatment and rehabilitation plan was completed on October 5, 2011 and indicated that the client will receive individual sessions five times a week and static group sessions one time a week. However, client record # 1 only included documentation of individual progress notes on the following dates: 10/4/11, 10/11/11, 10/18/11, 10/25/11, 11/4/11, and 11/14/11 as of November 30, 2011. Also, client record # 1 did not include documentation of static group notes as of November 30, 2011.
Client # 2 was admitted September 7, 2011. The individual treatment and rehabilitation plan was completed on September 8, 2011 and indicated that the client will receive individual sessions and static group sessions one time a week. However, client record # 2 only included documentation of individual progress notes on the following dates: 8/30/11, 9/14/11, 9/19/11, 9/27/11, 10/3/11, 10/12/11, 10/19/11, 10/21/11, 10/26/11, 11/2/11, and 11/8/11 as of November 30, 2011. Also, client record # 2 only included documentation of static group notes on the following dates: 9/12/11, 9/19/11, 9/26/11, 10/3/11, 10/10/11, 10/17/11, 10/24/11, 10/31/11, and 11/18/11 as of November 30, 2011.
Client # 3 was admitted October 11, 2011. The individual treatment and rehabilitation plan was completed on October 11, 2011 and indicated that the client will receive individual sessions and static group sessions one time a week. However, client record # 3 only included documentation of individual progress notes on the following dates: 10/11/11, 10/19/11, and 10/24/11 as of November 30, 2011. Also, client record # 3 only included documentation of static group notes on the following dates: 10/17/11, 10/24/11 and 10/31/11 as of November 30, 2011.
Client # 4 was admitted September 27, 2011. The individual treatment and rehabilitation plan was completed on September 30, 2011 and indicated that the client will receive individual sessions five times a week and static group sessions one time a week. However, client record # 4 only included documentation of individual progress notes on the following dates: 9/28/11, 10/5/11, 10/12/11, 10/19/11, 10/26/11, 11/4/11, 11/10/11, and 11/17/11 as of November 30, 2011. Also, client record # 4 only included documentation of a static group note on the following date: 11/15/11 as of November 30, 2011.
Client # 6 was admitted November 7, 2011. The individual treatment and rehabilitation plan was completed on November 9, 2011 and indicated that the client will receive individual sessions and static group sessions one time a week. However, client record # 6 only included documentation of individual progress notes on the following dates: 11/8/11 and 11/14/11 as of November 30, 2011. Also, client record # 6 only included documentation of a static group note on the following date: 11/15/11 as of November 30, 2011.
Client # 7 was admitted September 29, 2011. The individual treatment and rehabilitation plan was completed on September 30, 2011 and indicated that the client will receive individual sessions five times a week and static group sessions one time a week. However, client record # 7 only included documentation of individual progress notes on the following dates: 9/30/11, 10/7/11, 10/14/11, 10/21/11, 10/28/11, 11/4/11, 11/10/11, and 11/17/11. Also, client record # 7 only included documentation of a static group note on the following date: 11/15/11 as of November 30, 2011.
The findings were confirmed during an ongoing dialogue with the facility director on November 30, 2011 from approximately 3:15 P.M. to 4:00 P.M.
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Plan of Correction
Clients #1, #2, #3, and #7 have discharged from the program. The necessary corrections have been made in Client charts #4 and #6. An in-service facilitated by the Program Director took place on 12/9/11 to address regularity of counseling provided. Ongoing training will be provided by the Gaudenzia Training Institute. Counseling notes will be reviewed by Program Director weekly. Corrective actions will be instituted for non-compliance. The facility will be in full compliance by December 31, 2011. The Program Director will ensure compliance. |