INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the May 13, 2011 licensure renewal inspection. The follow-up inspection was conducted on November 30, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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, the facility failed to document that fire extinguisher training was provided upon employment in two of two personnel records reviewed.
The findings include:
On November 30, 2011, two personnel records were reviewed 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 records # 1 and 2.
Employee #1 was hired on September 5, 2011. There was documentation that employee #1 had fire extinguisher training but it was undated and therefore the inspector was unable to determine if it had been completed upon hire.
Employee #2 was hired on August 15, 2011. There was documentation that employee #2 had fire extinguisher training but it was undated and therefore the inspector was unable to determine if it had been completed upon hire.
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Plan of Correction
1. The Program Supervisor of Facility Operations will conduct an inservice on the proper use for all fire extiguishers and evacuation procedures for all new hires within three days of employment.
2. The Program Supervisor of Facility Operations will have each new employee complete a training evaulation with the date of the inservice documented.
3. The Administrative Coordinator will complete a fire extinguisher and evacuation training certifcate with the date of the training for each new hire.
4. The Administrative Coordinator will file in each new hire's personnel file a copy of the training evaluation and certificate.
5. The Administrative Coordinator will forward a copy of each new hire's training evaluation and certificate for fire extinguisher and evacuation procedures to Gaudenzia's Training Institute for emplyee files.
6. The Program Director will conduct a audit of each new hire's personnel file to ensure fire extinguisher and evacuation procedure trainings are completed and files 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 and the facility's policies and procedures, the facility failed to document a record of services in four of four client records.
The findings include:
On November 30, 2011, four 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, 3 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 August 8, 2011. Client record #1 did not include a record of service.
Client #2 was admitted to treatment on September 2, 2011. Client record #2 included a record of service but only documented services for individual counseling on 9/7/11 and 9/14/11. The record of services indicates services were rendered on 9/28/11 but it did not specify the type of service.
Client #3 was admitted to treatment on September 20, 2011. Client record #3 did not include a record of service.
Client #4 was admitted to treatment on October 7, 2011. 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 enter Intake Paperwork as the first entry on the record of service on the day of admission for all new intakes.
2. The Program Supervisor of Clinical Services will conduct an inserivce in January 2012 for all clinicians on proper documentation of the record of service.
3. The Clinical staff will enter service rendered on the Record of Service daily.
4. Program Supervisor will conduct a weekly audit of all clinical charts to ensure all reoords of service are accurate and complete as required.
5. The Program Director will conduct a monthly audit of the records of service to ensure compliance of the program Supervisor of Clinical Services' weekly audit. |
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 was still out of compliance at the time of the follow-up conducted on November 30, 2011.
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Plan of Correction
The Program Director will hold a staff meeting to have all staff complete training registration forms as required.
2. The Program Supervisor will complete all training plans and registrations and forward to Gaudenzia's Training Institute no later than 1/30/2012 as required.
3. All counselors will receive the required 25 hours of training within the first 6 months of 2012.
4. The Program Director will contact the Training Institute by 1/13/2012 for the new training schedule to insure the Program Supervisor of Clinical Services and staff have the outline of upcoming trainings. |