INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision which is a requirement for the position.
Employee #3 was promoted to the position of clinical supervisor on July 13, 2022 and is current in that position. Employee #3 did not complete a core curriculum as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
During week of 7-24-23 Clinical Supervisor was registered and is attending DDAP approved Clinical Supervisors Training.
In event a new Clinical Supervisor is hired, Program director will evaluate past supervisory experience and ensure that person meets qualifications as outlined in 704.6 (c). If potential candidate doesn't have necessary experience candidate will be registered within the first month of hire date. Program Director and Division Director will ensure compliance in this area. CQI team will audit program records quarterly to ensure staff compliance.
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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 a review of personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee #5 was hired as a counselor on November 28, 2022 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying bachelor's degree but not the required one year of clinical experience for a bachelor's level counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7-13-23. Program director submitted transcripts for employee #5 to demonstrate confirmation of Master's degree.
In an effort to prevent re-occurrence, Program director will ensure that all new hires will provided transcripts that demonstrate degree conferment. This will be reviewed with the Division Director to ensure accuracy.
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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 eight personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that three employees received the minimum of six hours of HIV/AIDS and four hours of TB/STD training within the regulatory timeframe.
Employee #6 was hired as a support staff member on August 11, 2020 and was due to have the communicable disease trainings no later than August 11, 2022. However, the facility provided no documentation of the completion of the communicable disease trainings as of the date of the inspection.
Employee #7 was hired as a support staff member on October 5, 2020 and was due to have the communicable disease trainings no later than October 5, 2022. However, the facility provided no documentation of the completion of the communicable disease trainings as of the date of the inspection.
Employee #8 was hired as a support staff member on February 16, 2021 and was due to have the communicable disease trainings no later than February 16, 2023. However, the facility provided no documentation of the completion of the communicable disease trainings as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Program director will ensure 3 employees shall complete required trainings by 9/30/23.
To prevent reoccurrence, Program director will develop training tracking tool/system to monitor monthly status of employee trainings status.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on June 22, 2023, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as a trash receptacle in the sallyport of the building was uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In effort to prevent reoccurrence, During next weekly meeting Program staff will be educated on program standards that require trash/dumpsters have all lids closed at all times. During monthly facility audit Program Director will ensure lids are closed on the dumpster. CQI will complete quarterly site visits to ensure this remains in compliance. In the event this not in compliance, findings will immediately be reported to the Division Director to correct. |
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
An initial physical plant inspection was conducted on June 20, 2023, to review all common areas for the onsite licensing inspections for multiple licenses at the physical plant address spanning June 20, 2023 through June 23, 2023. The facility failed to keep frozen food at or below 0 degrees Fahrenheit as the walk-in freezer in the kitchen was 12 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 26, 2023 the freezer was serviced and the temperature was adjusted to ensure it read at zero degrees. Staff checked all food and it was in the appropriate temperature range. Program director will ensure Kitchen staff check the freezer temperature daily and report the temperature on log. The Facilities Director will perform monthly safety checks and report issues to the Program Director as needed. Program Director will immediately follow up with the maintenance department should the freezer need to be serviced. The CQI Manager will perform a quarterly site inspection to ensure compliance.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
An initial physical plant inspection was conducted on June 20, 2023, to review all common areas for the onsite licensing inspections for multiple licenses at the physical plant address spanning June 20, 2023 through June 23, 2023. The facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company as the fire extinguisher in the basement pantry indicated that the most recent inspection and approval occurred in October 2021.
This is a repeat citation from the May 5, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director alerted the maintenance department on 7/21/2023 who has scheduled the fire extinguisher inspection agency to come to the facility on or before 8/21/2023 to inspect or replace this fire extinguisher as appropriate.
Fire Extinguishers are inspected at least monthly by facility staff which is documented on the fire Extinguisher tags and in the safety report. The Program Director will reveiw the safety report each month to ensure compliance.
In addition, fire extinguishers are monitored by the CQI Department during quarterly CQI site inspections and any findings will be reported to the Program Director for immediate action.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of seven client records, the facility failed to follow their policy and procedures related to medication administration and recordkeeping in three of seven applicable records reviewed. The facility policy indicates that staff will document on the medication administration record (MAR) the reason a medication was not given. Additionally, medication administration forms will include date and time of administration.
Client #3 was admitted on February 8, 2023 and discharged on March 1, 2023. The MAR for the administration of two medications did not document whether they were taken or the reason they were not administered on February 13, 2023 and February 14, 2023.
Client #5 was admitted on January 31, 2023 and was active at the time of the inspection. The MAR for the administration of one medication did not document whether it was taken or the reason it was not administered on June 22, 2023.
Client #7 was admitted on May 15, 2023 and was active at the time of the inspection. The MAR for the administration of two medications did not document whether they were taken or the reason they were not administered on June 5, 2023 and June 11, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program director will meet weekly with Nursing supervisor to review all missed medications for members and check that all required documentation is recorded according to policy and procedure. During quarterly audits, the CQI team will review charts to ensure documentation is occurring. Findings will immediately be reported to the Director of Nursing for follow-up as needed. |