INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on May 10, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia, Inc. of Coatesville 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee training records on May 10, 2012, the facility failed to assure that each employee received a written individual training plan.
The findings include:
A review of seven employee training records on May 10, 2012, revealed that the individual training in record #1 failed to be completed for the current year. The last individual training plan for Employee #1 was 05-03-2011.
A conversation with the administrative staff on May 10, 2012 confirmed this finding
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Plan of Correction
The Training Deparment will ensure that an individual training plan is developed and documented with all employees within required timeframes. This will be completed for all employees by Jan.31,2013 as per our policy. |
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 records on May 10, 2012, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
A review of four of seven personnel records, revealed that staff person #6 was missing the required training hours of HIV/Aids and STD/TB within the first year of employment.
Employee # 6 was employed since 02/28/2011 and is in the position of a counselor.
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Plan of Correction
As of 5/13/1 all staff including staff person #6 have received their HIV/AIDS, TB/STD trainings. Going forward all new hires are being tracked for trainings by training institute at corporate and at facility by the clinical supervisor to ensure that all mandatory trainings are completed in the required time frames. |
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 on a review of administrative materials during the onsite inspection, the annual audit was not completed by end of fiscal year 2011.
The findings include:
In a review of financial documentation provided during an on-site inspection on May 8, 2012, the facility failed to complete the annual audit by end of the 2011 fiscal year.
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Plan of Correction
The Director of Finance and Accounting will coordinate with the external independent public accountant to ensure that all future financial audits are completed within required timeframes. This will be completed by December 31, 2012 (6 months after June 30th; the close of our fiscal year) as per our policy. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client record during the onsite licensing inspection, the facility failed to document that clients were arrived of their rights in one of one records reviewed.
The findings included:
A review of eight client records on May 10, 2012 revealed there was no documentation to confirm that client # 6 was informed of his/her client rights.
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Plan of Correction
Client rights are now part of our orientation process. They will sign off on the form in the group where their rights have been explained. Clinical Supervisor is now monitoring
on the 1st and 15th of the month for new hires to ensure that clients are signing off on the client rights and that they are in the clients chart. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on the review of eight client records and an interview with the facility director, the facility failed to disclose policy and procedure during orientation to all clients.
The findings included:
During the onsite inspection of May 10, 2012, client records were reviewed. The facility failed to provide documentation of an orientation session in client record #6.
The findings were reviewed with the Facility Director on May 10, 2012, and they were not disputed.
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Plan of Correction
As of May 30, 2012 all clients are required to attend orientation. During this time they will be given a orientation packet. They are required during this group to sign off on the the required paperwork. This session is run by the Clinical Supervisor who then keeps a record of all clients attending the orientation group and monitors it on the 1st and 15th of each month. Client then in his/her own words acknowledges attending the orientation group. This is then reported to Director and Divisional Director. |