INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4 - 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. - Crossroads 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure each counselor assistant met the qualifications for the position of counselor within five years of employment in one of one personnel record.
Employee # 6 became a full-time counselor assistant on September 5, 2016. Employee # 6 is still in the position of counselor assistant and does not meet the qualifications for the position of counselor as of October 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This individual is no longer employed with Gaudenzia.
In the future, any staff member hired as a counselor assistant will adhere to all requirements set forth in 704.10 pertaining to work toward meeting qualifications for full counselor status within 5 years of employment.
The Division Director and Program Director, in collaboration with the Human Resources Department, will review employee files on at least a quarterly basis to ensure that all staff meet, or are working toward meeting all qualifications, as appropriate.
The Compliance department will review all plans of correction within 9 months to ensure full implementation.
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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 training records, the facility failed to document HIV/AIDS and TB/STD training in two of three records.
Employee # 11 was hired as support staff on September 26, 2017. HIV/AIDS and TB/STD training was due to be completed no later than September 26, 2019 but was not documented in personnel training record # 11.
Employee # 12 was hired as support staff on January 22, 2019. HIV/AIDS and TB/STD training was due to be completed no later than January 22, 2021 but was not documented in personnel training record # 12.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The 2 referenced employees will be scheduled for HIV/AIDS and TB/STD training at the earliest possible opportunity. This will be completed by 12/31/21.
The Division Director and Program Director will coordinate with the Gaudenzia Training department to make use of the DDAP Training Management System (TMS) to schedule all staff with outstanding training requirements immediately. There are currently no open training opportunities listed on the DDAP TMS. Program Directors will check these websites at least 2 times per week, in order to secure limited training opportunities.
Division Director and Program Director will monitor staff training plans on an at least quarterly basis to ensure that trainings are provided within required timeframes. This review will be documented as in a supervision note between the Division and Program Director.
The Training department is working to leverage our web-based training system to provide alerts to staff and managers regarding upcoming due dates for training requirement.
The Gaudenzia training department is also in contact with DDAP regarding development of internal training courses which will meet the DDAP requirements. This will help to ensure that we can provide these required trainings to our staff in a much more efficient manner.
The Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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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 training records, the facility failed to document 25 clock hours of annual training required for counselors for the January 1, 2020 - December 31, 2020 training year in one of one record.
Counselor # 5 was hired December 4, 2017. Only 12 clock hours of annual training were documented for the 2020 training year for counselor # 5.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The referenced employee will be immediately scheduled additional trainings in order to meet the required number of hours. This will be completed utilizing our web-based training system to complete our CARF accreditation requirements training by 11/30/21.
Program Director will monitor staff training plans on an at least quarterly basis to ensure that trainings are provided within required timeframes, meeting the required number of training hours. This review will be documented as in a supervision note between the Division and Program Director.
The Training department is working to leverage our web-based training system to provide alerts to staff and managers regarding upcoming due dates for training requirement.
The Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on October 5, 2021, the facility failed to maintain each bathroom in a functional manner at all times.
The third floor women's restroom near bedroom # 1 was observed to have several cracked, uneven ceramic tiles near the drain and in front of the shower which could cause an injury to clients utilizing the shower area.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All tiles on the bathroom floor were repaired on 10/12/21.
Facility Safety Rounds are conducted on at least a daily basis and documented on a rounds list which is maintained in a binder at the facility. The Division Director and Program Director will conduct at least weekly reviews of this documentation, and will ensure that any needed repairs to the physical plant are requested through the maintenance department, and will follow up to ensure that these are completed in a timely manner.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include the physical plant, and the Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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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 a review of personnel records, the facility failed to document fire extinguisher training was completed upon staff employment in three of four personnel records.
No fire extinguisher training was documented in the following records.
Employee # 7 was hired April 13, 2021.
Employee # 8 was hired February 9, 2021.
Employee # 9 was hired January 11, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These staff members will complete the Fire Extinguisher training by 11/12/21. This will be delivered by the Facilities Manager.
Going forward, staff will complete all required trainings within the required timeframes. This will be monitored by the Division Director and Program Director on at least a quarterly basis through review of staff training files. This review will be documented as in a supervision note between the Division and Program Director.
Additionally, the Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document that all personnel on all shifts were trained to perform assigned tasks during emergencies in three of four personnel records.
Emergency training was not documented for the following employees upon employment for their assigned shift.
Employee # 7 was hired April 13, 2021.
Employee # 8 was hired February 9, 2021.
Employee # 9 was hired January 11, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These staff members will complete the Fire Safety training by 11/12/21. This will be delivered by the Facilities Manager.
Going forward, staff will complete all required trainings within the required timeframes. This will be monitored by the Program Director on at least a quarterly basis through review of staff training files. This review will be documented as in a supervision note between the Division and Program Director.
Additionally, the Compliance department will conduct a review of all Plans of Correction within 9 months to ensure full implementation.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection, review of medication documentation and facility staff interviews on October 5, 2021, the facility failed to document quarterly inspections of the medication storage area from January 2021 through September 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Monthly inspection of all medication storage areas will be completed by the Nurse Manager utilizing a specific checklist to be maintained in the medication area. This will begin by 11/12/21.
The Division Director and Program Director will review documentation of this quarterly inspection to ensure that it is completed in a timely manner, and to address any concerns identified.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include medication storage areas, and the Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of detox client records, the facility failed to document follow-up information within seven days of discharge, per facility policy, in two of two records.
No follow-up information was documented in the following records.
Client # 9 was admitted August 23, 2021 and discharged August 30, 2021.
Client # 11 was admitted June 30, 2021 and discharged July 5, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up will be completed and documented for both of the clients identified by 11/12/21.
Follow up will be documented within 7 days for all clients post-discharge.
The Division Director and Program Director will conduct at least monthly audits of discharged charts to ensure that this is completed. Audits will be completed using the standardized audit tool.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include documentation of follow up, and the Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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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 review and update at least every thirty days in two of four client records.
Client # 8 was admitted May 16, 2021 and discharged August 24, 2021. The individual treatment plan was completed June 7, 2021. The only treatment plan update was documented on July 13, 2021.
Client # 14 was admitted August 13, 2021. The individual treatment plan was completed August 27, 2021. No treatment plan updates were documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will conduct an in-service training in collaboration with the Quality Assurance department by 11/12/21 with all clinical staff to ensure that all understand this requirement. The Clinical Supervisor will also review upcoming treatment plan due dates during daily treatment team meetings to remind staff of these deadlines, as well as at the end of shifts to ensure that they were completed.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include documentation of treatment plan updates, and the Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes, per facility policy, in two of six client records.
The facility's policy indicates case consultations will be documented within 10 days of admission and then every 30 days. No case consultations were documented in the following records:
Client # 2 was admitted July 13, 2021 and discharged August 11, 2021.
Client # 14 was admitted August 13, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will conduct an in-service training by 11/12/21 with all clinical staff to ensure that all understand this requirement.
The Clinical Supervisor will also review upcoming Case Consultation due dates during daily treatment team meetings to remind staff of these deadlines, as well as at the end of shifts to ensure that they were completed.
The Division Director, Program Director, and Clinical Supervisor will conduct at least monthly audits to ensure that this is occurring.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include documentation of case consultation notes, and the Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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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 residential client records, the facility failed to document follow-up information within seven days of discharge, per facility policy, in four of five records.
No follow-up information was documented in the following records.
Client # 4 was admitted May 14, 2021 and discharged May 27, 2021.
Client # 6 was admitted August 9, 2021 and discharged August 12, 2021.
Client # 8 was admitted May 16, 2021 and discharged August 24, 2021.
Client # 12 was admitted July 14, 2021 and discharged September 2, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up will be completed and documented for each of the clients identified by 11/12/21.
Follow up will be documented within 7 days for all clients post-discharge.
The Division Director and Program Director will conduct at least monthly audits of discharged charts to ensure that this is completed.
The Quality Assurance department will conduct at least quarterly reviews of the program, to include documentation of follow up, and the Compliance department will conduct a review of all plans of correction within 9 months to ensure full implementation.
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