INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from November 6 - 9, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and administrative documentation, the facility failed to follow its own policies regarding the completion of the following staff development components:
1) an assessment of staff training needs for 2012
2) an overall plan for addressing staff training needs for 2012
3) and an annual evaluation of the overall training plan for 2011
4) individualized training plans for 2012
The findings include:
The P&P Manual and administrative documentation were reviewed from November 6 - 7, 2012. The facility failed to adhere to its own time frames in regard to 4 out of the 4 areas identified above.
The facility's Staff Development Program specifies that the following components be completed no later than the identified time frames:
1) an assessment of staff training needs for 2012 - due by January 31, 2012
2) an overall plan for addressing staff training needs for 2012 - due by January 31, 2012
3) and an annual evaluation of the overall training plan for 2011 - due by December 31, 2011
4) individualized training plans for 2012 - due by January 31, 2012
The following administrative document was reviewed on November 7, 2012:
"Gaudenzia DRC, Inc., Annual Assessment Of Trainings, Wednesday, June 6, 2012"
The document referenced above was signed and dated by the Division Director as well as the Director of Human Resources on June 6, 2012. The document included the following plans, evaluations and / or assessments:
"Staff Training Comments, Evaluation of Training Effectiveness, Program Training Needs, Training Assessment and Plan, Overall Training Plan for Up Coming Year, 2012 Training Calendar."
Since the Evaluation of Training Effectiveness (2011), Training Assessment and Plan (2012), and the 2012 Training Calendar were not completed until June 6, 2012, all three elements were late.
In addition, six employee records requiring individual training plans for 2012 were reviewed on November 7, 2012. Two of six records, specifically #'s 1 and 2, contained treatment plans that were late as they were not completed by January 31, 2012.
Employee # 1 was hired on June 14, 2005. The individual training plan for 2012 was late as it was not completed until May 22, 2012.
Employee # 2 was hired on January 11, 2010. The individual training plan for 2012 was late as it was not completed until October 18, 2012.
The findings were reviewed with the Project Director during the exit interview and were not disputed.
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Plan of Correction
The Human Resource Director will develop a comprehensive staff development program for agency personnel that include an assessment of staff training needs, an overall plan for addressing these needs, a mechanism that will collect feedback on the completed trainings and an annual evaluation of the overall training plan by Janaury 31, 2013 . The individual training plans for each employee will be developed by January 31, 2013 with input from the employee and supervisor.
All training documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings.
Persons Responsible: Human Resource Director, Inpatient Director
Timeframe for Completion: January 31, 2013
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based upon a review of employee records, the facility failed to ensure that all employees received a minimum of 6 hours of HIV / AIDS training using a Department approved curriculum, within the required time frame.
The findings include:
Six employee records requiring documentation of HIV / AIDS training were reviewed on November 7, 2012. One of six records, specifically # 9, did not include documentation of 6 hours of HIV/AIDS training within the required time frame.
Employee # 9, a residential aide, was hired on June 13, 2007, and was required to receive 6 hours of HIV / AIDS training by June 13, 2009. However, the record contained documentation of HIV / AIDS training that was late as it was received by the employee on April 1, 2012.
The findings were confirmed by the Human Resources Department.
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Plan of Correction
Employees will receive a minimum of six (6) hours of HIV/AIDS using a DDAP approved curriculum. Counselors shall complete the training within the first year of employment and all other staff within the first two (2) years of employment.
All training documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings.
Persons Responsible: Human Resource Director, Inpatient Director
Timeframe for Completion: February 6, 2013
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based upon the physical plant inspection and a review of administrative documentation, the facility failed to provide verification that each client had a bed with a fire retardant mattress.
The findings include:
The physical plant inspection was conducted on November 8, 2012, from approximately 9:30 AM to 11:00 AM.
At the time of inspection, the facility maintained 34 beds for male clients on the 5th floor of the building. Mattress tags contained on 10 of 34 mattresses being used by clients did not include documentation that they were fire retardant. In addition, documentation reviewed after the physical plant inspection, which included photos / copies of mattress tags marked fire retardant, did not match the information contained on the 10 mattresses in question. Therefore, the facility was unable to verify that the 10 of 34 mattresses being used by male clients were fire retardant.
The mattresses without fire retardant tags were located in the following rooms:
Room # 523 - 2 of 2 mattresses
# 524 - 1 of 3 mattresses
# 521 - 1 of 2 mattresses
# 517 - 1 of 2 mattresses
# 511 - 1 of 2 mattresses
# 508 - 1 of 2 mattresses
# 506 - 2 of 2 mattresses
# 505 - 1 of 2 mattresses
The findings were confirmed by the Clinical Supervisor during the physical plant inspection.
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Plan of Correction
The facility will purchase only bedding that is clearly identified as fire retardant and in compliance with DDAP Policy 705.5 (a)(1). Documentation of compliance will include a tag attached to the mattress, bill of sale, etc.
Persons Responsible: Operations Director, Inpatient Director
Timeframe for Completion: February 6, 2013
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705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that all food items were stored off the floor.
The findings include:
The physical plant inspection was conducted on November 8, 2012, from approximately 9:30 AM to 11:00 AM.
The facility's pantry is located on the 1st floor near the Human Resources Department. While inspecting the pantry the Licensing Specialist observed that 3 boxes of juice were on the floor. In addition, while inspecting the walk-in freezer, which was accessed through the pantry, the Licensing Specialist observed that a box of chicken drums, a box of bread, and a box of green beans were on the floor.
The findings were confirmed by the Project Director during the exit interview.
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Plan of Correction
The facility will store all food items on shelves, pallets, or on carts. On December 10, 2012 the Director of Maintenance and Kitchen Services will facilitate the training on Food Service Policy 705.7 with the kitchen staff.
Monthly Continuous Quality Improvement (CQI) meetings will monitor the compliance with Food Service Policy 705.7.
Persons Responsible: Director of Maintenance and Kitchen Services, Inpatient Director
Timeframe for Completion: December 10, 2012 |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug and alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Administrative documentation, which included the project's annual fiscal audit, was reviewed on November 6, 2012.
As per administrative documentation, the project's fiscal year runs from July 1 to June 30. The project's annual fiscal audit for July 1, 2010 to June 30, 2011, was late as it was not completed until February 29, 2012.
The findings were reviewed with the Project Director during the exit interview and were not disputed.
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Plan of Correction
The Division Director under the supervision of the Executive Director will ensure that the agency's actual Annual Report is completed upon conclusion of the fiscal year.
Persons Responsible: Executive Director, Division Director
Timeframe for Completion: December 31, 2012 |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based upon a review of client records, the facility failed to ensure that individual treatment and rehabilitation plans included documentation of proposed support services.
The findings include:
Six client records requiring individual treatment plans were reviewed from November 8 - 9, 2012. Individual treatment plans contained in four of six records, specifically #'s 1, 2, 5 and 6, did not include proposed support services.
Client # 1 was admitted on August 31, 2012, and was still an active client at the time of inspection. The record contained an individual treatment plan that was signed and dated by the client on September 12, 2012. However, the treatment plan did not include proposed support services.
Client # 2 was admitted on September 14, 2012, and was still an active client at the time of inspection. The record contained an individual treatment plan that was signed and dated by the client on September 21, 2012. However, the treatment plan did not include proposed support services.
Client # 5 was admitted on September 14, 2012, and was still an active client at the time of inspection. The record contained an individual treatment plan that was signed and dated by the client on September 21, 2012. However, the treatment plan did not include proposed support services.
Client # 6 was admitted on October 5, 2012, and was still an active client at the time of inspection. The record contained an individual treatment plan that was signed and dated by the client on October 12, 2012. However, the treatment plan did not include proposed support services.
The findings were reviewed with the Clinical Supervisor during the exit interview.
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Plan of Correction
A record-keeping training to include a review of the treatment planning systems was facilitated on November 16, 2012. The training ensured that all staff is trained to include documentation of proposed support services as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.52(a).
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible: Division Director of Clinical Services, IP Program Director
Timeframe for Completion: February 6, 2013
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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 upon the review of client records, the facility failed to document updated treatment plans that included an assessment of the client's progress as it related to the stated goals on the comprehensive treatment plan.
The findings include:
Six client records requiring updated treatment plans were reviewed from November 8 - 9, 2012. The facility failed to document the client's progress as it related to the stated goals on the comprehensive treatment plan in two of six records, specifically #'s 1 and 5.
Client # 1 was admitted on August 31, 2012, and was still an active client at the time of inspection. The record contained an individual treatment plan that was signed by the client on September 12, 2012, and an updated treatment plan that was dated October 10, 2012. However, the updated treatment plan did not include documentation of the client's progress toward 3 of 3 goals & objectives identified on the treatment plan.
This finding was confirmed by the Clinical Supervisor during the record review.
Client # 5 was admitted on September 14, 2012, and was still an active client at the time of inspection. The record contained an individual treatment plan that was signed and dated by the client on September 21, 2012, and an updated treatment plan that was dated October 21, 2012. However, the updated treatment plan did not include documentation of the client's progress toward 2 of 3 goals & objectives identified on the treatment plan.
This finding was reviewed with the Clinical Supervisor during the exit interview and was not disputed.
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Plan of Correction
A record-keeping training to include a review of the treatment planning systems was facilitated on November 16, 2012. The training ensured that all staff is trained to include document updated treatment plans that included an assessment of the client's progress as it relates to the stated goals on the comprehensive treatment plan as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.52(b).
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible: Division Director of Clinical Services, IP Program Director
Timeframe for Completion: February 6, 2013
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based upon a review of client records, the facility failed to maintain a complete client record to include a 'record of services' provided.
The findings include:
Six client records requiring documentation of a 'record of service' were reviewed from November 8 - 9, 2012. Four of six records, specifically #'s 2, 4, 5, and 6, contained a 'record of service' that was incomplete, had sections that were missing, or it contained inaccurate information.
Client # 2 was admitted on September 14, 2012, and was still an active client on the date of inspection. At the time of inspection, a 'record of service' was missing for the time frame of September 14 - 16, 2012. In addition, the 'record of service' contained in the record included documentation of an individual session and a group session for the same date and time: November 8, 2012, from 10 AM to 11 AM. Since the client could not be attending both sessions at the same time the 'record of service' contained inaccurate information.
Client # 4 was admitted on September 26, 2012, and was still an active client on the date of inspection. At the time of inspection, the record was missing a 'record of service' for the time frame of September 27, 2012 to October 8, 2012. In addition, the 'record of service' was incomplete as individual sessions documented by progress notes were missing for the following dates:
September 27, 2012
October 5, 12, 17, and 24, 2012
November 1, 2012
Client # 5 was admitted on September 14, 2012, and was still an active client on the date of inspection. The 'record of service' was incomplete as individual sessions documented by progress notes were missing for the following dates:
September 17, 21, and 28, 2012
October 1, 9, 17, and 24, 2012
November 1, 2012
In addition, the 'record of service' contained in record # 5 included documentation of the client attending an individual session and a community meeting on the same date and at the same time: November 17, 2012, from 9 AM to 10 AM. Since the client could not be attending both sessions at the same time the 'record of service' contained inaccurate information.
Client # 6 was admitted on October 5, 2012, and was still an active client on the date of inspection. At the time of inspection, the record was missing a 'record of service' for the time frame of October 5 - 7, 2012 and October 15 - 21, 2012. In addition, the 'record of service' was incomplete as individual sessions documented by progress notes were missing for the following dates:
October 15, 23, and 30, 2012
November 1, 2012
The findings were reviewed with the Clinical Supervisor during the exit interview and were not disputed.
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Plan of Correction
A record-keeping training to include a review of the Record of Service was facilitated on November 16, 2012 to ensure that all staff document progress notes on the Record of Service as required by the Division of Drug and Alcohol Licensure.
The chartsw were reviewed and the Record of Service was entered.
All Record of Services documentation and compliance will be reviewed weekly and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance.
Persons Responsible: Division Director of Clinical Services, IP Program Director
Timeframe for Completion: February 6, 2012
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