INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12 through 13, 2011 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:
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Plan of Correction
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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 on a review of the facility's letters of agreement and an interview with the Administrative Coordinator, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric and medical coverage.
The findings include:
The letters of agreement were reviewed on May 13, 2011. The facility did provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage, however the agreement had expired on April 30, 2010. A note was attached to the agreement which stated the renewal had been mailed on May 5, 2011 for signatures.
An interview with the Administrative Coordinator confirmed that facility had not yet renewed their contract for emergency medical and psychiatric coverage.
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Plan of Correction
The Administrative Coordinator will develop a computerized spreadsheet with names of referral agencies and the effective date of the referral letters to implement an audit system for letters of agreement.
The Administrative Coordinator will conduct an audit of all refearral letters of agreement bi-monthly and submit the dpreadsheet to the Program Director at the completion of the audit for the review.
The Administrative Coordinator will preapre letters of agreement for referrals and mail and/or hand deliver 60 days prior to the expiration date of said letters of referral agreements. |
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 the review of personnel records and an interview with the Training Manager, the facility failed to document that fire extinguisher training was provided upon employment in one of two personnel records reviewed.
The findings include:
On May 10, 2011, two personnel records were review for documentation that fire extinguisher training was provided upon employment. The facility did not document that fire extinguisher training was provided upon employment in personnel record # 6.
Personnel # 6 was hired on 3/28/11, but the training certificate indicated this training occurred on 5/11/11.
During an interview the Training Manager confirmed there was no prior documentation of emergency training for employee #6.
This is a repeat citation:
The facility was previously cited for noncompliance with this standard. This area of noncompliance was also identified during the licensing inspection conducted on May 27, 2010.
In response to the citation issued on May 27, 2010, the facility's plan of correction submitted on 6/18/2010 and approved on 6/23/2010 stated the following:
"Staff member #6 received Fire and Safety training on March 15th 2010. A copy of #6 training certificate was pulled from the facility personnel record and faxed to the Corporate office.
To ensure the training certificates are in the staff records at the Corporate Office, the Administrative Coordinator will obtain a copy of the training certificates from each staff member. The Administrative Coordinator will then fax a copy of each certificate to the Corporate office to be filed.
The Program Supervisor and Administrative Coordinator will conduct random audits at the Corporate Office to ensure compliance monthly."
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Plan of Correction
The Program Supervisor of Facility Operations will conduct an inservice training for fire extinguisher use and evacuation procedures for all new hires within the first 3 days of employment.
The Program Supervisor of Facility Operations will submit to the new Program Director copies of the training attendance signature sheets and training evaluation form to insure compliance.
The Administrative Coordinator will make a copy of both the signature page and training evaluation form for the facility personnel chart for the new hire and file.
The Administrative Coordinator will mail and/or fax the original signed copy along with the training evaluation form to the Gaudenzia Training Institute Manager as required and attach the transmission form to document if faxed. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record log and a conversation with the Facility Director, the facility failed to document alternate exits had been used during monthly fire drills in the last year.
The findings include:
The fire drill record log was reviewed on May 12, 2011. The log was reviewed from the time period covering June 2010 to May 2011. For every month during the time period reviewed, the column which read "Exit Used" indicated "ALL". Based on the documentation the inspector was unable to determine if the facility alternated the use of exits during monthly fire drills.
This was confirmed with the Facility Director during a conversation held on May 12, 2011.
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Plan of Correction
The Program Supervisor of Facility Operations will develop an "A, B, C, D, E," etc. exit route system for fire drill exits.
The Program Supervisor will post the appropriate letter near the door of each exit to indicate the assigned letter for said door.
The Program Supervisor will conduct an inservice for all staff to introduce the implemented system as well as an inservice outlining the correct manner in which to document a fire drill.
The Porgram Supervisor will ensure all staff complete a training evaluation form as required and submit to the Administrative Coordinator.
The Administrative Coordinator will file each training evaluation in each staff's personnel file as required.
The new Program Director will audit the Fire Drill log monthly to insure compliance and for accuracy by initialing and dating each fire drill form. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in five of eight client records.
The findings include:
On May 12-13, 2011, eight client records were reviewed for documentation of type and frequency of treatment and rehabilitation services. The facility did not document a treatment plan to include type and frequency of treatment services, as per facility policy, in client records # 1, 2, 4, 6, and 7.
The facility's policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
"Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved."
In client record #1, the treatment plan documented on 3/16/11 did not include type and frequency of treatment and rehabilitation services.
In client record #2, the treatment plan documented on 3/9/11 did not include type and frequency of treatment and rehabilitation services.
In client record #4, the treatment plan documented on 12/21/10 did not include type and frequency of treatment and rehabilitation services.
In client record #6, the treatment plan documented on 11/16/10 did not include type and frequency of treatment and rehabilitation services.
In client record #7, the treatment plan documented on 6/11/10 did not include type and frequency of treatment and rehabilitation services.
This is a repeat deficiency.
The facility was previously cited for noncompliance with this standard. This area of noncompliance was also identified during the licensing inspection conducted on May 27, 2010.
The facility was previously cited for noncompliance with this standard. This area of noncompliance was also identified during the licensing inspections conducted on May 27, 2010, October 6, 2009 and May 27, 2009.
The facility was previously cited for noncompliance with standard 709.52 Treatment and rehabilitation services- Type and frequency of treatment. This area of noncompliance was also identified during the licensing inspections conducted on May 27, 2010 (plan of correction submitted on 6/18/2010 and approved on 7/1/2010); October 6, 2009 (plan of correction submitted on 11/13/2009 and approved on 11/20/2009); and May 27, 2009 (plan of correction submitted on 6/23/2009 and approved on 8/19/2009).
In response to the citation issued on May 27, 2010, the facility's plan of correction submitted on 6/18/2010 and approved on 7/1/2010 stated the following:
" Plan of Correction:
The Clinical Program Supervisor will conduct a Clinical In-service training on the documentation to always include the type and frequency on the treatment plans.
During the weekly Treatment Team the Clinical Supervisor will audit the clinical charts to review the compliance of the treatment plans and its frequency to ensure compliance. During Supervision the Supervisors will review with the clinical staff the documentation of the type and frequency in the treatment plans. The Director will conduct random audits of clinical charts to monitor the documentation of the type and frequency is on each treatment plan monthly:
In response to the citation issued on October 6, 2009, the facility's plan of correction submitted on 11/13/2009 and approved on 11/20/2009 stated the following:
" The type and frequency of services will be removed from the action steps section of the treatment plan and placed in the frequency column. An in-service was conducted to ensure compliance with all clinical staff. The supervisor will perform weekly audits to ensure compliance to this refinement. "
In response to the citation issued on May 27, 2009, the facility's plan of correction submitted on 6/23/2009 and approved on 8/19/2009 stated the following:
" All staff had attended several clinical documentation trainings. The clinical program supervisor was given disciplinary action for not being complete in her chart audits of the clinical staff. The clinical staff, having already reviewed the policy, and having attended several trainings and in-services, received disciplinary action addressing their inconsistency in adhering to the policy. The Program supervisor will conduct weekly audits addressing the type and frequency of treatment and rehabilitation. The program director will conduct chart audits of the program supervisor to ensure the thoroughness and completeness of her work (audits). "
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Plan of Correction
1. The new Program Director will conduct an inservice with all newly hired clinicians regarding the clinical policy for documenting the type and frequency of treatment and rehabilitation on treatment plans within the first week of hire.
2. The new Program Supervisor of Clinical Services will review all treatment plans to insure type and frequency of treatment and rehabilitation are documented as treatment plans are due and submitted for his/her signature as required.
3. The new Program Director will audit all clinical charts on the 2nd Friday of each month in preparation of continued quality improvement reports for current month of report to insure that type and frequency of treatment and rehabilitation is reflected on all treatment plans in that month.
4. The new Program Spuervisor of Clinical Services will receive a Corrective Action for all treatment plans that do not reflect type and frequency of treatment and rehabiliation as required. |
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 on the review of client records, the facility's policies and procedures, and an interview with the facility director, the facility failed to document a record of services in three of eight client records.
The findings include:
On May 12-13, 2011, eight client records were reviewed for documentation of a record of services. The facility did not document a record of services, as per facility policy, in client records # 1, 2, and 4.
The facility's policy titled "PROCEDURE FOR INTAKE DOCUMENTATION OF HISTORIES", dated January 2009, states:
Record of Services: All services rendered to a client shall be documented on the Record of Services form, which is maintained in the client record. The form should initially be completed with the intake paperwork. The Counselor or staff person scheduled to provide a service shall record the date a service is scheduled to be provided, the specific service and the initials of the staff responsible for the service. Documentation of this should be made promptly after the appointment is scheduled. The client's attendance status and the duration of the service shall be noted as soon as the disposition is known. A ROS is completed daily.
Client #1 was admitted to treatment on 3-16-2011. Client record #1 did not include a record of service.
Client #2 was admitted to treatment on 3-8-2011. Client record #2 did not include a record of service.
Client #4 was admitted to treatment on 12-16-2010. Client record #4 did not include a record of service.
This was discussed with the facility director on May 13, 2011. The director confirmed the record of services were missing from the records.
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Plan of Correction
1. The Administrative Coordinator will make the intial entry on the record of service indicating "Intake Paperwork" on the 1st day of admission for all new admits.
2. Clinicians will input entries on the record of servicefor all clients assigned to their respective caseload at the end of each week according to service delivery.
3. The Program Supervisor will review each clinical chart in supervison with each counselor on a bi-weekly basis to insure accuracy and completeness of the records of service as stated in policy and procedure.
4. The Program Director will review random charts in preparation for completing the monthly Continued Quality Improvement report to insure records of service are included in the audit for completeness and timeliness. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility's policies and procedures, and an interview with the Facility Director, the facility failed to document an aftercare plan in one of three client records.
The findings include:
On May 12-13, 2011, three client records were reviewed for documentation of an aftercare plan. The facility did not document an aftercare plan, as per facility policy, in client record # 5.
The facility's policy titled "AFTERCARE PLANNING" states:
Aftercare planning is initiated during the first week of treatment. In an effort to promote continued growth of the progress made while in treatment, the Gaudenzia attempts to complete individualized aftercare plan with each client regardless of the discharge status or treatment disposition.
Initial discharge plan begins within 24 hours of admission while formal arrangements are made upon determination of the client's readiness for discharge. This is the individual's plan for the future, including identification of the client ' s personal goals and objectives. It should focus on sustaining and building on the progress achieved during treatment and should have input from all significant persons, especially the client.
Client #5 was admitted to treatment on 10-28-2010 and discharged on 2-25-2011. Client record #5 did not include documentation of an aftercare plan as of the date of May 13, 2011.
An interview was held with the facility director on May 13, 2011. The facility director confirmed there was no aftercare plan in the record.
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Plan of Correction
1. The After Care Plan will be made a "living" document upon admission for each client whereas documentation on the aftercare plan will begin with the first individual session.
2. The assigned counselor will complete the top portion of the after care plan which asks for referral information,presenting factors, etc within the first week of admission. The clinician will also document with the client as the client progresses through the level system of Broad Street entires pretaining to aftercare.
3. The Program Supervisor for Clinical Services will audit charts on a monthly basis for continued quality improvement reports to insure that aftercare plans have monthly entries as required until client's completion.
4. The Program Director will review random charts monthly to insure after care plans are 'living" documents and progression is evident. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On May 13, 2011 the facility was again found to be out of compliance with the following standards:
705.10 Fire Safety- Instruct staff in the use of fire extinguishers upon employment. This area of noncompliance was also identified during the licensing inspection conducted on May 27, 2010 (plan of correction submitted on 6/18/2010 and approved on 6/23/2010).
709.52 Treatment and rehabilitation services- Type and frequency of treatment. This area of noncompliance was also identified during the licensing inspections conducted on May 27, 2010 (plan of correction submitted on 6/18/2010 and approved on 7/1/2010); October 6, 2009 (plan of correction submitted on 11/13/2009 and approved on 11/20/2009); and May 27, 2009 (plan of correction submitted on 6/23/2009 and approved on 8/19/2009).
704.7 Qualifications for the position of counselor- This area of noncompliance was also identified during the licensing inspection conducted on October 6, 2009 (plan of correction submitted on 11/13/2009 and approved on 11/20/2009).
704.11(d) Staff development program - Training requirements for project directors and facility directors. This area of noncompliance was also identified during the licensing inspection conducted on May 27, 2010 (plan of correction submitted on 6/18/2010 and approved on 6/23/2010)
704.11 Staff development program - failure to ensure counselors have 25 documented training hours per training year- This area of noncompliance was also identified during the licensing inspection conducted on May 27, 2009 (plan of correction submitted on 6/24/2009 and approved on 8/12/2009).
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Plan of Correction
1 The Program Director will meet with each Program Supervisor once to review the approved POC.
2. Each Program Supervisor will meet with their respective staff persons once to review the approved POC with the Program Director present in said meeting.
3. The Program Director will meet with each Program Supervisor on a monthly basis to discuss progress in each area sited as a deficiency to monitor progress.
4. The Program Director will be responsible for developing and implementing a plan with each Program Supervisor, Administrative Coordinator, etc., in the case of deviation from the action steps oulined in the POC. |
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 the review of personnel records and an interview with the Human Resources Director, the facility failed to ensure each counselor met the qualifications for the position of counselor prior to being hired.
The findings include:
On May 10, 2011 eight personnel records were reviewed to ensure that each counselor met the required qualifications for the position. Employee #7, hired on June 21, 2010 as a Counselor I, has a Bachelor's degree in a related field; however, lacked the required one year of clinical experience in a health or human service agency. After a review of employee #7's resume, it was found they had less than one year of clinical experience prior to employment with the facility.
On May 11, 2011 a conversation was held with the Human Resources Director and the findings were confirmed.
This is a repeat deficiency.
The facility was previously cited for noncompliance with this standard. This area of noncompliance was also identified during the licensing inspection conducted on October 6, 2009. In response to the citation issued on October 6, 2009, the facility's plan of correction submitted on 11/13/2009 and approved on 11/20/2009 stated the following:
" This staff person has been transferred to a non licensed facility.
The Program Director, in consultation with the Program Supervisor, will review all new hires, transfers from other sites and dialogue with the HR Department to confirm that the degree is verified and applicable to the DOH regulations. "
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Plan of Correction
1. The Program Director will obtain a copy of the Department of Health's staffing requirements for Counselors.
2. The Program Director will interview potential counselors according to the staffing guidelines relating to experiences and education levels.
3. The Program Director will follow through with reference checks to verify potential counselor's years of clinical experience.
4. The Program Director will submit all required documents to the Mental Health Division Director for review to insure that potential counselors have the required credentials and clinical experience for counselors according to DOH regulations. |
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 a review of personnel records and the Staffing Requirements Facility Summary Report and interviews with the Training Manager and Facility Director, the facility failed to ensure that each counselor completed at least 25 clock hours of training per year in one of four records reviewed.
The findings include.
On May 10, 2011, four counselors' personnel records were reviewed to ensure that each had completed the required 25 clock hours of training per year. According to the Staffing Requirements Facility Summary Report, the facility training year runs from January 1, 2010 to December 31, 2010. The facility failed to ensure employee #8 had 25 training hours for the 2010 training year.
Employee # 8 was hired as a counselor on December 24, 2007. Employee # 8 had only 12 documented clock hours of training during January 1, 2010 through December 31, 2010.
On May 11, 2011 a conversation was held with the Training Manager in which it was confirmed that there were no further training hours documented for employee #8. This was reconfirmed on May 12, 2011 with the Facility Director.
This is a repeat deficiency.
The facility was previously cited for noncompliance with this standard. This area of noncompliance was also identified during the licensing inspection conducted on May 27, 2009. In response to the citation issued on May 27, 2009, the facility's plan of correction submitted on 6/24/2009 and approved on 8/12/2009 stated the following:
" The Administrative Coordinator's newly developed computer generated file will notify the administrator coordinator when trainings are due. The Administrative Coordinator will schedule the trainings in accordance to the policy. "
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Plan of Correction
1. The Administrative Coordinator will be responsible for monitioring all staff training hours by submitting to the Program Director at the end each month a spreadsheet of all trainings staff attended for the month with the number of hours for each training.
2. Both Program Supervisors will receive a copy of the staff training hours spreadsheet at the end of each month to monitor for achievement of required training hours for all staff supervised under their component.
The Program Director will be responsible for scheduling training for all staff under her/his direct supervision to insure that the required training hours requirement are met.
The Program Supervisors will be responsible for scheduling trainings for all staff under his/her direct supervision to insure that the required training hours requirements are met. |