INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2015 and May 19, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. West Chester 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records reviewed.
The findings include:
Three clinical personnel records for the position of counselor were reviewed during the administrative review at the headquarters office on 5/6/2015. The facility failed to ensure that employee # 7 met the educational requirements for the position of counselor.
Employee # 7 was hired as a bachelor's level counselor on 9/23/2013. Employee # 7 did not meet the qualifications for the position of counselor as they did not have a bachelor's degree with an approved major.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 4/30/2014 inspection.
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Plan of Correction
By June 30, 2015
Program Director did correct the deficiency by did change the position of Counselor to Counselor Assistant. After a review of positions available for transfer. Counselor #7 who did not meet the qualifications, had her duties changed on 6-1-15 and formally demoted effective on 6/20/15.
Program Director will offer employees who do not meet the requirements for Program Counselor other appropriate employment options to include but not be limited to Program Counselor Assistant.
Program Supervisor will review all employee files on a bi-annual basis to assure that all employees meet the established criteria.
Facility Administrative Manager will routinely ensure that new hires credentials are present.
Responsible employees:
Program Director, Program Supervisor and Facility Administrative Manager |
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 on a review of the project's staffing requirements facility summary report (SRFSR) and personnel records, the project failed to ensure that all personnel received a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of TB/STD training using a Department approved curriculum.
The findings include:
The facility failed to ensure that two of the employees completed the required training.
Employee # 8 was hired as a teacher on 10/18/1993. This employee failed to complete the HIV/AIDS and TB/STD training as of the date of the inspection.
Employee # 9 was hired as a teacher on 9/10/2007. This employee failed to complete the HIV/AIDS and TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the 4/30/2014 inspection.
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Plan of Correction
By September 30, 2015,
Facility Administrative Manager will provide documentation which indicates that all staff have completed the mandatory training's within the regulatory time frames. For those who have not, Employee #8 and #9, the Program Director shall ensure that the employees are scheduled to take the training in order to meet the standard by 9/30/15
Program Supervisor will review all employee files on a bi-annual basis to ensure that files contain the required training's and that all employees are in compliance with mandatory regulatory time frames.
Responsible employees:
Program Director, Program Supervisor, Facility Administrative Manager |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that there were paper towels or a mechanical dryer in each bathroom.
The findings include:
A physical plant inspection was conducted on 5/19/2015 at approximately 11:00 AM.
There were neither paper towels nor a mechanical hand dryer in Bathroom A on the second floor in the men's dorm at the time of the physical plant inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/19/2015, this was resolved during the time of the survey.
Program Supervisor will assure that a daily check of the bathrooms are completed by House Managers and that paper towels are present throughout the day as per standard P057
Responsible Parties:
Program Supervisor, House Managers
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705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure smoking was limited to the designated smoking areas.
The findings include:
A physical plant inspection was conducted on 5/19/2015 at approximately 11:00 AM. The designated smoking area is located outside by the front entrance to the facility.
A strong odor of cigarette smoke permeated throughout the bathroom next to Room 6 in women's dorm. Furthermore, intact cigarette ashes were observed on the window sill in the bathroom.
There were intact cigarette ashes and a water-soaked cigarette butt observed in the sink furthest from the entrance to the Bathroom C on the second floor in the men's dorm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/1/2015 Program Supervisor will instruct staff to keep all residents off of the dorm area floors during treatment times and to be monitored during the times on the dorm.
Staff will be required to check in areas to ascertain that residents are not smoking on the unit.
A daily log will be kept indicating times and areas checked and the results.
Responsible Parties:
Program Supervisor, House Managers, Counselors |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information that includes all of the content required by regulation.
The findings include:
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 5/18/2015 - 5/19/2015. The facility failed to ensure that all of the required content information was documented on the informed and voluntary consent to release information forms in client record #8.
Client # 8 was admitted on 11/17/2014 and discharged on 2/18/2015. Client # 8's informed and voluntary consent to release information forms to the client's wife, sister and mother-in-law each dated 11/21/2014 did not specify the type of information authorized for release.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
Beginning July 1, 2015
Program Supervisor will review all charts during regular supervision to ensure that all informed and voluntary consent to release information forms and necessary documentation due is present and correct.
Clinical files that are lacking or missing documentation will result in corrective actions for the counselor responsible for the chart.
Responsible Employee:
Program Supervisor, Administrative Staff and Counselors
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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 complete physical examination upon intake in five of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a physical examination were reviewed on 5/18/2015 - 5/19/2015. The facility failed to document a complete physical examination that includes client vital signs in client records # 1, 4 and 7. In addition, the facility failed to verify the physical examination was completed during the intake process in client records #3 and 9.
Client # 1 was admitted on 2/27/2015. The documentation of the client's physical examination dated 3/10/2015 did not include the client's vital signs.
Client # 3 was admitted on 2/17/2015. The client's documented physical examination did not include the date and signature of the medical professional that completed the examination.
Client # 4 was admitted on 12/23/2014. The documentation of the client's physical examination dated 10/12/2014 did not include the client's vital signs.
Client # 7 was admitted on 2/17/2015. The documentation of the client's physical examination dated 2/24/2015 did not include the client's vital signs.
Client # 9 was admitted on 11/16/2014. The client's documented physical examination did not include the day of the month that physical examination was completed. The date was listed as "11/ /14". The facility was unable to verify that the physical examination was done during the intake process.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/1/2015, facility supervising nurse will conduct weekly chart audits to determine compliance and completeness. Physicals will be scheduled as part of the admission/medical intake protocol.
All charts will be reviewed by the Program Supervisor and Nursing Supervisor to ensure that a timely Medical History and Physical Exam is completed by our Physician or a Certified Registered Nurse Practitioner for each client.,
Facility will utilize a physician or Certified Registered Nurse Practitioner as a secondary provider when primary provider is unavailable to assure that all physical examinations are completed and signed during the intake process.
Program Supervisor will review all admissions' charts on a monthly timetable to verify compliance.
Responsible Staff:
Supervising Nurse, Certified Registered Nurse Practitioner, Program Supervisor, Physician and Program Director. |
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 the review of client records, the facility failed to document a complete psychosocial evaluation upon intake in three of nine client records reviewed.
The findings include:
Nine client records requiring documentation of a psychosocial evaluation were reviewed on 5/18/2015 - 5/19/2015. The facility failed to document a complete psychosocial evaluation upon intake in client records # 4, 7 and 9.
Client # 4 was admitted to treatment on 12/23/2014. The only psychosocial evaluation documented in the client's record was dated 10/6/2014 and was from a previous admission. An updated psychosocial evaluation was not completed.
Client # 7 was admitted to treatment on 2/17/2015. The psychosocial evaluation documented in the client's record was neither signed nor dated by the counselor. The facility was unable to verify that the psychosocial evaluation was done upon intake.
Client # 9 was admitted to treatment on 11/6/2014. The psychosocial evaluation documented in the client's record was neither signed nor dated by the counselor. The facility was unable to verify that the psychosocial evaluation was done upon intake.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/1/2015 Clinical Supervisor or Program Supervisor will review the charts of all new admissions 72 hours after admission to be sure that the chart is in compliance and can accurately reflect the recommended treatment course based on a completed bio-psycho social evaluation and assessment.
Program Director will conduct monthly unannounced chart audits to gauge compliance.
Responsible Staff:
Program Director, Program Supervisor, Clinical Supervisor
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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 the frequency and/or type of treatment services on the individual treatment and rehabilitation plan in five of nine client records reviewed.
The findings include:
Nine client records requiring documentation of the frequency of treatment services on the individual treatment and rehabilitation plans were reviewed on 5/18/2015 - 5/19/2015. The individual treatment and rehabilitation plans contained in client records # 2, 6, 7, 9 and 10 did not include the frequency of treatment services.
Client # 2 was admitted to treatment on 3/4/2015. The client's individual treatment and rehabilitation plan dated 5/6/2015 did not specify the frequency of individual and group counseling therapy.
Client # 6 was admitted to treatment on 10/14/2014. The client's individual treatment and rehabilitation plan dated 11/14/2014 did not specify the type and frequency of counseling therapy.
Client # 7 was admitted to treatment on 2/17/15. The client's individual treatment and rehabilitation plan dated 2/17/2015 did not specify the frequency of individual and group counseling therapy.
Client # 9 was admitted to treatment on 11/6/2014. The client's individual treatment and rehabilitation plan dated 12/15/2014 did not specify the frequency of individual and group counseling therapy.
Client # 10 was admitted to treatment on 11/14/2014. The client's individual treatment and rehabilitation plans dated 12/14/2014 and 1/14/2015 did not specify the frequency of individual and group counseling therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/1/2015 Clinical Supervisor or Program Supervisor will review the treatment plans prior to signing off on them to assure that all elements required including the frequency and/or type of treatment services are properly documented. Program Director will conduct a random audit of charts monthly to determine compliance.
On 6-24-15 all clinical staff will attend an in-service provided by the Program Director, on the appropriate use of the individual treatment plan and update forms including timeliness, time and frequency sections and goal setting.
Responsible Staff: Program Director, Program Supervisor, Clinical Supervisor
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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 document a treatment plan update at least every 30 days in three of nine client records reviewed.
The findings include:
Nine client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 5/18/2015 - 5/19/2015. The facility failed to document a treatment plan update at least every 30 days in client records # 6, 7 and 9.
Client # 6 was admitted on 10/14/2014 and discharged on 1/12/2015. The client's last treatment plan update was completed on 11/14/2014.
Client # 7 was admitted on 2/17/2015 and discharged on 3/24/2015. The client's initial treatment plan was completed on 2/17/2015. There was no documentation of a treatment plan update for March 2015.
Client # 9 was admitted on 11/6/2014 and discharged on 2/4/2015. The last two treatment plan updates for the client were completed on 12/15/2014 and 1/19/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/1/2015, the Clinical Supervisor or Program Supervisor will monitor due dates for treatment plans and updates to ensure compliance in client record.
The clinical team will meet weekly to review treatment plans and provide case consultation.
The Program Supervisor or Program Director signature will indicate that the treatment plan was reviewed and is in compliance.
On 6-24-15 all clinical staff will attend an in-service provided by the Program Director, on the appropriate use of the individual treatment plan and update forms including timeliness, time and frequency sections and goal setting.
Responsible Staff:
Program Director, Program Supervisor, Clinical Supervisor |
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 the review of client records, the facility failed to ensure that a complete record was documented in six of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a complete client record were reviewed on 5/18/2015 - 5/19/2015. The facility failed to document a complete record in client records # 1, 2, 3, 5, 6 and 10.
Client # 1 was admitted on 2/27/2015 and was still an active client at the time of the inspection. The progress notes for the group sessions that the client attended on 5/14/2015, 5/12/2015, 5/11/2015, 5/7/2015 and 5/4/2015 did not indicate the client's participation in the group sessions. Furthermore, there were 13 group sessions and 4 individual sessions that the client attended that were not documented on the record of service logs.
Client # 2 was admitted on 3/4/2015 and was still an active client at the time of the inspection. The progress notes for the group sessions that the client attended on 5/14/2015, 5/11/2015, 5/7/2015, 4/20/2015 and 4/6/2015 did not indicate the client's participation in the group sessions. Furthermore, there were 2 group sessions and 3 individual sessions that the client attended that were not documented on the record of service logs.
Client # 3 was admitted on 2/17/2015 and was still an active client at the time of the inspection. The progress notes for the group sessions that the client attended on 5/12/2015, 4/22/2015 and 3/31/2015 did not indicate the client's participation in the group sessions. Furthermore, there was no documentation of a record of service for February 2015 - May 2015.
Client # 5 was admitted on 11/30/2014 and discharged on 12/3/2014. There was no documentation of a record of service for December 2014.
Client # 6 was admitted on 10/14/2014 and discharged on 1/12/2015. The record of service logs did not include the individual sessions that the client attended on 11/28/2014, 11/21/2014 and 10/24/2014.
Client # 10 was admitted on 11/14/2014 and discharged on 2/12/2015. There was no documentation of progress note for the individual sessions that the client attended on 2/9/2015, 2/2/2015, 1/26/2015, 1/19/2015, 1/12/2015, 1/5/2015, 12/29/2014, 12/22/2014, 12/15/2014, 12/8/2014, 12/1/2014, 11/24/2014 and 11/17/2014. Furthermore, there were 12 individual sessions that client attended that were not documented on the record of service logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/30/2015: The Program Director and Program Supervisor will conduct a staff meeting with staff members to ensure that the understanding of the documentation of all records are placed in the chart in a timely fashion. Also that all services rendered must be documented on the Record of Service. The counselors will be provided with a reasonable time frame to ensure all documentation is completed and filed.
The Program Supervisor will be responsible for monitoring compliance by randomly reviewing the charts on a monthly basis.
Responsible Staff:
Program Director, Program Supervisor |