INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6, 2013 to March 7, 2013 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed 12 clock hours of required training in one of two personnel records reviewed.
The findings include:
From March 6, 2013 to March 7, 2013, two personnel records requiring documentation of 12 clock hours of training were reviewed. The facility failed to provide documentation of 12 clock hours of training in one of two personnel records reviewed, specifically, personnel record # 1.
Employee # 1 is the project director and was hired for his current position in 1988. The facility's training year was from January 1, 2012 to December 31, 2012. Employee # 1 was required to complete 12 clock hours of annual training hours by December 31, 2012. The facility was afforded an opportunity on March 6, 2013 and March 7, 2013 to present documentation of 12 clock hours of annual training hours for the project director. Documentation of annual training hours for the project director was not presented for review.
The findings were confirmed during an interview with the facility director and division director on March 7, 2013 at approximately 3:00 P.M.
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Plan of Correction
Program Director will ensure that the Corporate office forwards, the Project Directors 12 clock hours of training, whereby the Program Director will forward said document to the Office of Mental Health so that it can be it can be verified.
The Training Institute will be responsible for ensuring that the Project Directors receives 12 clock hours of training on a yearly basis. |
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, the facility failed to ensure that each counselor completed 25 clock hours of required training in one of three personnel records reviewed.
The findings include:
From March 6, 2013 to March 7, 2013, three personnel records requiring documentation of 25 clock hours of training were reviewed. The facility failed to provide documentation of 25 clock hours of training in one of three personnel records reviewed, specifically, personnel record # 5.
Employee # 5 is a counselor and was hired on October 22, 2012. The facility's training year was from January 1, 2012 to December 31, 2012. Employee # 5 was required to complete 25 clock hours of annual training hours by December 31, 2012. However, personnel record # 5 only had documentation of 11 clock hours of annul training hours for the January 1, 2012 to December 31, 2012 training year as of March 7, 2013.
The findings were confirmed during an interview with the facility director and division director on March 7, 2013 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on September 5, 2012; May 11, 2012; November 30, 2011; and May 13, 2011 for noncompliance with this standard.
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Plan of Correction
Employee #5 has been registared for 25 clock hours of training by the Program Director. Moving forward, Program Director will ensure that all counselors will be registared for and complete 25 hours of reguired training per agency policy. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on observations on March 7, 2013, the facility failed to maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
The findings include:
A physical plant inspection was conducted on March 7, 2013. The bedrooms in the facility were inspected to verify that the facility had a bedroom reserved in with a smoke detector and fire alarm for a resident with a hearing impairment. It was observed during the inspection from approximately 10:00 A.M. to 11:00 A.M. that the facility did not have a bedroom reserved with a smoke detector and fire alarm for a resident with a hearing impairment.
The findings were confirmed during an interview with the one of the house managers and registered nurses at approximately 11:05 A.M.
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Plan of Correction
The program will designate 1 bedroom on the men's floor and 1 bedroom on the women's floor that will be equipped with a strobe light and bed shaker, smoke detector and fire alarm for hearing impared individuals.
The Program Director will disignate the rooms for the hearing impared, and moving forward will ensure that the rooms that are designated, remain as such. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of two personnel records reviewed.
The findings include:
From March 6, 2013 to March 7, 2013, two personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not ensure that all personnel on all shifts completed emergency training in one of two personnel records reviewed, specifically, personnel record # 5.
Employee # 5 is a counselor and was hired October 22, 2012. Employee # 5 was due to complete emergency training upon employment at the facility. Employee # 5 completed emergency training but the emergency training did not include a date of completion as March 7, 2013.
The findings were confirmed during an interview with the facility director on March 7, 2013 at approximately 1:00 P.M.
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Plan of Correction
Moving forward, Program Director will check all emergency training documentation to ensure completeness, with particular emphasis on ensure that the date of completion of the training is present on the training form.
Moving forward, the Program Supervisor will ensure that all new employees receive the emergency training in timely manner. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of the facility's administrative documentation, the facility failed to provide documentation that the goals and objectives for the 2012 to 2013 fiscal year were approved by the governing body.
The findings include:
The facility's administrative documentation and goals and objectives for the 2012 to 2013 fiscal year were reviewed on March 6, 2013 and March 7, 2013. On March 6, 2013 and March 7, 2013, the Licensing Specialist asked to see documentation that the goals and objectives for the 2012 to 2013 fiscal year were approved by the governing body. The facility was afforded an opportunity to present govern body minutes, a sign off page by the govern body, or any other documentation reflecting that the govern body approved the goals and objectives for the 2012 to 2013 fiscal year. Documentation reflecting that the govern body approved the goals and objective for the 2012 to 2013 fiscal year was not presented for review.
The findings were confirmed during an interview with the facility director and division director on March 7, 2013 at approximately 3:00 P.M.
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Plan of Correction
The Clinical Director at the Corporate Office will be responsible for ensuring that the goals and objective are presented by the CEO, to the governing body for approval for the fiscal year (moving forward) are signed off by the governing body.
The facility will obtain a copy of the approved goals and objectives (2012 - 2013) with the signature of approval from the governing body. This will be completed by 5/30/13. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to document the individual treatment and rehabilitation plan in accordance with their policy and procedures in five of eight client records reviewed.
The findings include:
The facility's policy titled: "Intake Process/Paperwork," states:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor, and Medical Director (when applicable) within 5 days in residential and within 30 days in outpatient."
From March 6, 2013 to March 7, 2013, eight client records requiring documentation of an individual treatment and rehabilitation plan were reviewed. The facility did not document an individual treatment and rehabilitation plan according to their policy and procedures in five of eight client records reviewed, specifically, client records # 2, 4, 6, 7, and 8.
Client # 2 was admitted January 17, 2012. The individual treatment and rehabilitation plan was due January 22, 2013. However, the individual treatment and rehabilitation plan was not completed until March 4, 2013.
Client # 4 was admitted December 6, 2012. The individual treatment and rehabilitation plan was due December 11, 2012. However, the individual treatment and rehabilitation plan was not completed until December 21, 2012.
Client # 6 was admitted February 7, 2013. The individual treatment and rehabilitation plan was due February 12, 2013. However, the individual treatment and rehabilitation plan was not completed until March 5, 2013.
Client # 7 was admitted February 4, 2013. The individual treatment and rehabilitation plan was due February 9, 2013. However, the individual treatment and rehabilitation plan was not completed until February 21, 2013.
Client # 8 was admitted February 1, 2013. The individual treatment and rehabilitation plan was due February 6, 2013. However, the individual treatment and rehabilitation plan was not completed until February 18, 2013.
The findings were confirmed during an interview with the facility director and division director on March 7, 2013 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on September 5, 2012 and May 11, 2012 for noncompliance with this standard.
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Plan of Correction
Moving forward, the first individual treatment plan will be completed and approved within 5 days of the individuals admit date. Moving forward, the clinical supervisor will ensure that this policy is adhered to and that all treatment plans are completed within the time fames as specified.
The Clinical Supervisor will conduct weekly audits of the charts in order to assure policy compliance and ensure that timeframes are correct, until the staff have demonstated compliance, at which time random audits will be conducted. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in seven of eight client records reviewed.
The findings include:
From March 6, 2013 to March 7, 2013, eight client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plan were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in seven of eight client records reviewed, specifically, client records # 1, 3, 4, 5, 6, 7, and 8.
Client # 1 was admitted December 19, 2012. The individual treatment and rehabilitation plan was completed January 7, 2013, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2013.
Client # 3 was admitted January 30, 2013. The individual treatment and rehabilitation plan was completed February 18, 2013, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2013.
Client # 4 was admitted December 6, 2012. The individual treatment and rehabilitation plan was completed December 21, 2012, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2013.
Client # 5 was admitted January 25, 2013. The individual treatment and rehabilitation plan was completed February 14, 2013, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2013.
Client # 6 was admitted February 7, 2013. The individual treatment and rehabilitation plan was completed March 5, 2013, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2013.
Client # 7 was admitted February 4, 2013. The individual treatment and rehabilitation plan was completed February 21, 2013, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2013.
Client # 8 was admitted February 1, 2013. The individual treatment and rehabilitation plan was completed February 18, 2013, but did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of March 7, 2013.
The findings were confirmed during an interview with the facility director and division director on March 7, 2013 at approximately 3:00 P.M.
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Plan of Correction
The clinical staff will update the the following individual treatment plans in the following client charts: charts #1,3,4,5,6,7 and 8. Each updated individual treatment plan in the above stated client records will include the proposed support services for each individual.
Moving forward, the clinical supervisor will conduct weekly audits of the client treatment plans, to ensure that support services are indicated on each plan. Once this has been domonstrated by the clinical staff, the clinical supervisor will conduct ramdom chart audits to ensure compliance. |
709.52(e)(3) LICENSURE Legal support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on an interview with the facility director and division director, the project failed to assists clients in obtaining legal supportive services when necessary.
The findings include:
On March 6, 2013 and March 7, 2013, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining legal supportive services when necessary. The facility was unable to provide documentation showing that the facility assists clients in obtaining legal supportive services when necessary.
The findings were confirmed during an interview with the facility director and division director on March 7, 2013 at approximately 1:00 P.M.
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Plan of Correction
The facility has submitted and obtained a referral agreement for legal services which the clients can utilize for legal support.
The Administrative Coordinator will ensure tha the letter of agreement remains current and is renewed every 2 years. The Program Director will ensure that this task is completed as directed. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to verify that work done by the client at the project is an integral part of his treatment and rehabilitation plan in eight of eight client records reviewed.
The findings include:
From March6, 2013 to March 7, 2013, eight client records requiring documentation for verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan. The facility did not document verification of work therapy in the comprehensive treatment plan and/or treatment plan update in eight of eight client records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, 7, and 8.
Client # 1 was admitted December 19, 2012. The comprehensive treatment plan was completed January 7, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 1 did not include documentation of work therapy in the comprehensive treatment plan as of March 7, 2013.
Client # 2 was admitted January 17, 2013. The comprehensive treatment plan was completed March 4, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 2 did not include documentation of work therapy in the comprehensive treatment plan as of March 7, 2013.
Client # 3 was admitted January 30, 2013. The comprehensive treatment plan was completed February 18, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 3 did not include documentation of work therapy in the comprehensive treatment plan as of March 7, 2013.
Client # 4 was admitted December 6, 2012. The comprehensive treatment plan was completed December 21, 2012 and the treatment plan update was completed January 23, 2013. The facility was required to document work therapy on the comprehensive treatment plan and the treatment plan update. However, client record # 4 did not include documentation of work therapy in the comprehensive treatment plan and treatment plan update as of March 7, 2013.
Client # 5 was admitted January 25, 2013. The comprehensive treatment plan was completed February 14, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 5 did not include documentation of work therapy in the comprehensive treatment plan as of March 7, 2013.
Client # 6 was admitted February 7, 2013. The comprehensive treatment plan was completed March 5, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 6 did not include documentation of work therapy in the comprehensive treatment plan as of March 7, 2013.
Client # 7 was admitted February 4, 2013. The comprehensive treatment plan was completed February 21, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 7 did not include documentation of work therapy in the comprehensive treatment plan as of March 7, 2013.
Client # 8 was admitted February 1, 2013. The comprehensive treatment plan was completed February 18, 2013. The facility was required to document work therapy on the comprehensive treatment plan. However, client record # 8 did not include documentation of work therapy in the comprehensive treatment plan as of March 7, 2013.
The findings were confirmed during an interview with the facility director and division director on March 7, 2013 at approximately 3:00 P.M.
This is a repeat citation. The facility was cited on September 5, 2012 for noncompliance with this standard.
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Plan of Correction
Treatment Plans for client #1,2,3,4,5,6,7,8 have been amended to include the work therapy for each individual stated above. Moving forward, the clinical supervisor will ensure that each comprehensive treatment plan for all clients has a work therapy goal in place, which is an integral part of his/her treatment plan. The Program Director will follow-up to ensure that this goal is present all all treatment plans and that this goal documentatiion remains consistant throughout the client's length of stay within the facility. |