INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia Inc. 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on review of five personnel records conducted on March 10, 2020, the facility failed to provide documentation of the required 25 training hours for a counselor.
Employee # 3 was hired as counselor on October 24, 2015 and was in this position at the time of the inspection. A review of the employee record indicated only 10 hours of annual training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
0083
The Program Director will ensure that each counselor receives a minimum of 25 hours training per year in the areas identified in the regulations. The Administrative Coordinator will join mailing lists from external training resources such as Single County Authorities, PA Certification Board, and Dept of Drug & Alcohol Programs to increase awareness of training and notify Director & Counselors. The Director will schedule trainings as needed for the employees, utilizing the Relias Learning Management System, and external training sources in conjunction with employee needs and interests. The Director will review & report ongoing monitoring of training attendance documentation and tracking of cumulating hours in the monthly Continuous Quality Improvement meeting. Target Date: 4 /30/20
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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 a physical plant inspection conducted on March 10, 2020, the facility failed to maintain each bathroom in a clean and sanitary manner at all times. The client restroom located on the first floor lobby area had an exhaust fan that with an exuberant amount of dirt and debris.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P067
The first floor bathroom was thoroughly cleaned by staff on 3/11/20. A house manager's meeting was held by the Director on 3/18/20. Monthly cleaning of vents has been added to the facility cleaning schedule with completion being checked off by the House Manager on duty. Ongoing conformance will be monitored by the Director via monthly walk through and report via the Continuous Quality Improvement process. Target Date: Resolved 3/18/20
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705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection conducted on March 10, 2020, the facility's kitchen was observed to have what appeared to be mouse droppings in the kitchen cabinets.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P091
The rodent droppings were removed and the area properly cleaned/sanitized by staff on duty on 3/10/20 promptly after discovery. The contracted extermination vendor was called on 3/10/20 and serviced the facility on 3/11/20. This area has been added to the weekly cleaning schedule with oversight by staff on duty. Ongoing conformance will be monitored by the Director via monthly walk through and report via the Continuous Quality Improvement process. Target Date: Resolved 3/18/20
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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 a review of five personnel records conducted on March 10, 2020, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
Employee # 2 was hired for the current position on October 21, 2019 and was still employed at the time of the inspection. Employee #2's personnel record did not contain documentation of fire extinguisher training.
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Plan of Correction
P139
The employee lacking documentation of fire extinguisher training received instruction on 3/11/20 and it was documented accordingly in the employee training record. The Director will assure that all future hired staff receive documented fire extinguisher instruction upon employment. The Director and Administrative Coordinator will assure completion of first week orientation training certificates/evaluations and monitor continued conformance via a Monthly Training Report. Target Date: Resolved 3/11/20
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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 a review of five personnel records conducted on March 10, 2020, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee # 2 was hired for the current position on October 21, 2019 and was still employed at the time of the inspection. Employee #2's personnel record did not contain documentation of emergency training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
P145
The employee lacking documentation of emergency safety training received instruction on 3/11/20 and it was documented accordingly in the employee training record. The Director will assure that all future hired staff receive documented emergency safety training upon employment. The Director and Administrative Coordinator will assure completion of first week orientation training certificates/evaluations and monitor continued conformance via a Monthly Training Report. Target Date: Resolved 3/11/20
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on three of seven records reviewed on March 10, 2020, the facility failed to provide a complete consent to release form to include documentation of a copy being offered to the client.
Client # 1 was admitted on January 13, 2020 and was still active at the time of the inspection. Consent to release forms signed and dated on January 14, 2020 to a funding source, drug and alcohol, hospital, and pharmacy did not provide documentation that the client was offered a copy.
Client # 2 was admitted on October 24, 2019 and was still active at the time of the inspection. A consent to release form signed and dated on December 23, 2019, to York County Area and consent forms dated December 12, 2019 to a healthcare provider and Catholic Harvest Charities did not provide documentation that the client was offered a copy.
Client # 3 was admitted on December 23, 2019 and discharged on February 20, 2020. A consent to release form signed and dated on December 23, 2019, to a county agency did not provide documentation that the client was offered a copy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
0289
The Director will assure that a copy of a client consent is offered to the client. On 3/17/20, the Director reviewed in clinical staff meeting the importance of staff checking off the appropriate box on a consent form indicating whether the client accepted or refused a copy of the signed consent. Ongoing conformance will be monitored monthly via report in the Continuous Quality Improvement process. Target Date: Resolved 3/17/20.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on an onsite licensing renewal inspection conducted on March 10, 2020, the facility failed to provide documentation of an inspection of the medical storage room being conducted at least quarterly.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
0323
The med storage area was inspected on 3/11/20 by the Director and documented accordingly. The Director will assure the monthly inspection of medication storage areas and med/cart is completed and documented by trained staff in compliance with State and Federal laws, including verification of what is inspected, who did the inspection, separate storage of disinfectants and external use drugs from oral and injectable medications, appropriate storage conditions for insure medication stability, removal of outdated drugs, and availability of copies of drug-related regulations in the appropriate area. A copy of all inspection reports will be maintained by the Administrative Coordinator. Monitoring of continued conformance will be conducted by the Director and reported via the Continuous Quality Improvement process. Target Date: Target Date: Resolved 3/11/20.
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