INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5, 2007 through September 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Broad Street 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 and a plan of correction is due on October 1, 2007.
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Plan of Correction
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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 on a review of personnel and training documentation, the facility failed to document 4 hours of STD/TB training within the first two years of employment for employee #7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 a review of personnel and training records and staff schedules, the facility failed to ensure sufficient first aid and CPR coverage for overnight shifts on the following dates: 08/19/07, 08/20/07, 08/22/07, 08/23/07, 08/24/07, 08/26/07, 08/27/07, 08/28/07, 08/29/07, 08/30/07 and 09/01/07. Employees scheduled on these dates did not have documentation of first aid training or CPR certification.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel and training records on August 14, 2007, the facility failed to provide documentation of 12 hours of training for employee #2. Only 4 hours of training was documented for the 2006 training year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection conducted on September 6, 2007, the facility failed to ensure one bathroom was ventilated. The exhaust fan in the bathroom attached to the sole client bedroom on the first floor was inoperable.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the review of the temperature logs for August 2007 through September 6, 2007, the facility failed to ensure frozen food was kept at or below 0 degrees Fahrenheit. The freezers in the basement and on the first floor were approximately 20 and 10 degrees above 0 each day, respectively.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill log, the facility failed to document that the fire alarm or smoke detector was set off during each drill for the past eleven months.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on a review of administrative documentation, the facility failed to include a statement of activities and accomplishments for the preceding year.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation, the facility failed to include available resources and time frames for achievement of the project's goals and objectives.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based upon a review of administrative documentation, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 the physical plant inspection conducted on September 6, 2007 from 11:00 AM to 12:30 PM, the project failed to maintain client records in a locked storage container. The storage area on the second floor connected to female bedroom #1 was unlocked and contained closed client records in cardboard boxes. The storage area was also used to store toiletries and other non-clinical items.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to comply with the restriction imposed at 4 Pa. Code, Subsection 255.5 (b). The facility allowed medication information to be released to the clients's probation/parole officer in two of four records reviewed, #2 and 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of administrative policy and procedure and medication administration records, the facility failed document when, and if, clients received medications as prescribed in four of five clients reviewed, #1, 2, 3 and 4
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 complete psychosocial evaluation in four of four records reviewed, #1, 2, 3 and 4. The psychosocial evaluation did not include an assessment of the client's support systems, coping mechanisms and attitude towards treatment in three of four client records reviewed, #1, 2 and 3. The psychosocial evaluation was missing in one of four client records reviewed, #4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 include goals with measurable criteria in three of three client records reviewed, #1, 2 and 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 complete treatment plan update in four of four records reviewed, #1, 2, 3 and 5. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 facility failed to document that clients received regular and scheduled individual treatment sessions from June through July 2007 in two of five client records reviewed, #1 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of administrative and clinical documents, the facility failed to demonstrate that legal services could be obtained for clients.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of four records reviewed, #5, 6 and 7.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |