INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5-6, 2009 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 November 20, 2009.
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Plan of Correction
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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 facility policy and personnel records, the facility failed to document the qualifications for the position of counselor in one of two counselor records reviewed.
The findings include:
The facility failed to follow their policy titled GOVERNING BODY COMPLIANCE WITH STAFFING REQUIREMENTS DATED January, 2009.
Facility policy titled Governing Body Compliance With Staffing Requirements states:
" Gaudenzia programs adhere to the staffing plan established by the parent organization.
The project is committed to staff competency and complies with the staffing requirements set forth by the Department of Health, Division of Drug and Alcohol program licensing in Chapter 70 [sic]
Evidence of compliance with staff credentialing, competency, and training regulations is documented in employee personnel files and the project's Staff Training Book. "
The facility failed to follow their policy titled QUALIFICATIONS FOR POSITION OF COUNSELOR January, 2009
Facility policy titled QUALIFICATIONS FOR POSITION OF COUNSELOR states:
" Counselors shall meet the qualifications as outlined in Chapter 704 staffing regulations. "
Two counselor personnel records were reviewed on October 5-6, 2009. One of two counselor ' s records lacked documentation to verify that the counselor met the requirements of chapter 704 staffing regulations.
Employee # 6 did not meet the qualification for the position of counselor.
Personnel record # 6 contained documentation of an Associate ' s Degree, but the major was not in a related field.
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Plan of Correction
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.
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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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, the facility failed to document a minimum of 6 hours of HIV/AIDS training and/or 4 hours of tuberculosis and sexually transmitted diseases training in one of seven personnel records.
The findings include:
Seven personnel records were reviewed on October 5-6, 2009. All seven were required to have documentation of 6 hours of HIV/AIDS training and 4 hours of TB/STD training. The facility did not document 4 hours of TB/STD training in personnel record # 6.
Personnel record # 6, a counselor, was hired in February 2006. TB/STD training was required to be documented within the first year of employment, but this training was not documented at the time of inspection.
This is a repeat deficiency from the 5/27/2009, 5/22/2008 and the 9/06/2007 licensing inspections.
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Plan of Correction
Personnel record #6 was a transfer from another program. The timeliness of her core trainings occurred prior to Broad Street and can not be undone.
Employee #6 has been scheduled for the TB/STD training
The Administrative Coordinator will monitor all trainings to ensure the required training is completed in the first year of employment.
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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 the review of facility policy, personnel records and facility schedule for the month of September, the facility failed to ensure that at least one person certified in CPR was onsite during the project's hours of operation.
The findings include:
The facility failed to follow their policy titled PLAN FOR ASSESSMENT OF STAFF TRAINING NEEDS dated April, 2008 (included in the Policy and Procedure Manual dated January, 2009).
Facility policy titled PLAN FOR ASSESSMENT OF STAFF TRAINING NEEDS section titled Mandatory Training stated:
" All House Managers, staff members and those staff assuming shift coverage shall be trained in, an approved First Aid course and Cardiopulmonary Resuscitation. It shall be the responsibility of the employee to arrange a convenient training time -with the Supervisor in which this requirement may be completed. For all new employees, these trainings must be completed within the first ninety (90) days of employment with the agency. "
CPR certification records and the staff schedule were reviewed on October 5-6, 2009. The facility was required to document CPR certification to a sufficient number of staff persons. The facility did not have sufficient staff members with CPR certification on the 12:00 AM to 8:00 AM shift and on the 4:00 PM to 12:00 AM shift.
During the month of September, the facility did not have at least one person certified in CPR on the 12:00 AM to 8:00 AM shift on September 1, 2, 4, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 20, 21, 23, 24, 25, 26, 27, 27, 29 and 30.
During the month of September, the facility did not have at least one person certified in CPR on the 4:00 PM to 12:00 AM shift on September 1, 7, 8, 14, 15, 16, 21, 22 and 28.
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Plan of Correction
Staff for the 4 ? 12am shift and the 12am to 8am shift have received CPR training. The Program Supervisor will review all new hire personnel files to ensure CPR and core trainings are scheduled or have occurred.
Program Supervisor will monitor as CPR certifications and schedule trainings prior to the expiration dates. The Director will monitor that a staff person will be CPR certified on each shift.
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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 a tour of the facility ' s physical plant, the facility failed to maintain cold food at or below 40 tour of the physical plant was conducted on October 5, 2009 at approximately 2:00 PM. The temperature of the refrigerator in the basement was 45 The refrigerator temperature was rechecked again on October 6, 2009 at 9:30 AM and at again at 1:30 PM, but the temperature remained at 45 the temperature log for the refrigerator consistently documented the temperature as 42 since August 1, 2009.
This is a repeat deficiency from the 5/27/2009 licensing inspection..
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Plan of Correction
Plan of Correction:
The Program Supervisor contacted American Kitchen and they repaired the thermostat the same day.
The Program Supervisor will review the temperature chart on a daily basis to ensure the temperature will remain below 40 degrees. When the temperature of the refrigerator is above 40 degrees the Program Supervisor will inform the Director and the Program Supervisor will place a repair order to the contractor.
The designated staff persons were re-educated on the regulations and procedures for refrigerator/freezer
Temperature monitoring.
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a tour of the facility's physical plant, the facility failed to light interior exits and stairs at all times.
The findings include:
A tour of the physical plant was conducted on October 5, 2009 at approximately 2:00 PM. The facility was required to light interior exits and stairs at all times. The interior emergency exit stairway was not lighted on the first floor at the time of inspection. The facility representative stated that they needed to contact an electrician to repair the light fixture.
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Plan of Correction
Plan of Correction:
The light fixture has been repaired.
To ensure monitoring of the fixtures within the facility, The Program Director will conduct weekly inspections of the facility.
During the Fire and Safety run throughout the facility, staff will report and repairs needed, lights malfunctions to the Program Supervisors for repairs.
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705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a tour of the facility's physical plant, the facility failed to maintain each stairway exceeding two steps with a well secured handrail.
The findings include:
A tour of the physical plant was conducted on October 5, 2009 at approximately 2:00 PM The facility did not have a handrail for the emergency exit stairs in the basement. The facility representative confirmed that the rail was not present and had simply been missed previously.
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Plan of Correction
The Program Supervisor placed a work order in to have a handrail installed.
A handrail has been installed for the emergency exit stairs in the basement.
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709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in four of four client records.
The findings include:
Four active client records were reviewed on October 5-6, 2009. The facility failed to document an informed and voluntary consent from the client for the release of client information in four of four records reviewed.
Client records #1, 2, 3 and 4 documented correspondence with a government agency releasing client information, but the facility did not document informed and voluntary consent from the clients ' for the release of the information.
Additionally, client record # 3 documented the release of the client ' s Massachusetts criminal history to a government agency.
This is a repeat deficiency from the 5/27/2009 licensing inspection.
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Plan of Correction
The Program supervisor will audit the release of Confidentiality forms for three months in the charts for compliance.
If after three months the confidentiality forms are not in compliance, the Director will randomly review the clinical charts on a quarterly basis to ensure that facility is in compliance.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of facility policy and client records, the facility failed to document a physical examination within seven days from the date of admission as per facility policy in two of four client records reviewed.
The findings include:
The facility failed to follow their policy and procedure titled Intake & Admit Plan dated January, 2009.
Facility policy titled Intake & Admit Plan Section " A " subsection " 6 " states: " A physical examination shall be scheduled for the resident during or immediately following completion of the intake (Residential). Physical examinations will occur within 1 week of admission (DOH) or within 72 hours of admission (CBH) except if the client is admitted on a weekend or holiday as per details outlined in the physical exam section 709.51. b. 5. "
Six client records were reviewed on October 5-6, 2009. Of those six, physical examinations were reviewed in four records. The facility failed to document a physical examination within 7 days from the date of admission in client records #2 and 4.
Client record # 2 admission date 7/20/09, but physical exam documented 7/29/09
Client record # 4 admission date 8/11/09, but physical exam documented 8/20/09
This is a repeat deficiency from the 5/27/2009 licensing inspection.
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Plan of Correction
A letter of agreement with ______________
To complete physicals in a timely manner.
The Eastern Regional Director has been notified of this deficiency and has initiated a search for medical staff to assist in the larger numbers of clients being admitted to Gaudenzia facilities.
The Health Service staff (Nurse Manager) will call the physician the same day that the new client is admitted to schedule a physical examination.
When the physician is not available within the five days of admission.
The Health Service staff will contact the 850 North 11th Street (Drexel Health) and schedule an appointment within the five days to comply with the regulations.
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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 a review of facility policy and procedures and client records, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in four of four client records.
The findings include:
The facility failed to follow their policy and procedure titled PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN dated January, 2009.
Facility policy titled PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN item number 4 states: "An action plan, which will indicate more specifically the steps to be taken in order to accomplish the established goal. The action plan will also designate the person responsible for each step, i.e. client, counselor, Medical Director, etc. 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. The action plan will address the other support services in which the client is to participate including, but not limited to: medical, psychiatric, or psychological service, legal or economic assistance and Double Trouble and/or 12-step meeting attendance. In addition, the steps will relate to the Discharge Goals of the client."
Four active client records were reviewed on October 5-6, 2009. The facility did not document a treatment plan to include type and frequency of treatment and rehabilitation services in four of four client records, #1, 2, 3 and 4.
This is a repeat deficiency from the 5/27/2009 licensing inspection..
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Plan of Correction
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. |