INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2024, 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. Winner Co-Occurring Women and Children Program 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms located in the basement and the upper level of the building.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia has been granted a DDAP exception waiver to 705.4 (3) allowing video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This exception waiver was granted as of 6/18/24.
Gaudenzia is adding language to our consent forms to obtain informed consent from all clients to allow video-only recording strictly for safety and security purposes in the common areas of the program, including areas which may be used for group sessions. This language will be added to the consent forms no later than 6/30/24 and will then be reviewed and signed by all current clients prior to their next counseling session.
In the interim, the program will disable any camera which is positioned in such a way as to capture video of any counseling session. These cameras will be enabled once all clients have signed the consents, no later than 7/12/24. |
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
Based on a physical plant inspection, it was observed that the facility failed to ensure that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. There were two fire extinguishers located in the kitchen that were last inspected in March 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility had the two Fire extinguishers serviced on May 21st, 2024. The Recovery Support Supervisor will complete weekly facility safety inspections that include inspection of fire extinguishers. This will be documented on a facility safety inspection form. Any issues identified or inspections becoming due within the next month will be reported to the Program Director. The Program Director will complete monthly physical plant audits to include facility fire extinguishers and document findings on the Physical Plant Audit tool and upload to SharePoint. If a fire extinguisher is to be inspected within the following month, the program director will contact the fire extinguisher company, Boardman, to schedule the inspection. It will be ensuring the Program ensure this Directors responsibility to ensure this occurs |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility ' s policy and procedure manual in two out of four personnel records reviewed. The facility ' s policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee #1 was hired on September 9, 2019 as the project director and is still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024.
Employee #2 was hired on July 25, 2022 as the facility director and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until March 25, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All Gaudenzia Managers will ensure that Annual Performance Evaluations are completed, reviewed with the employee during a documented supervision session, and acknowledged via signature by both parties no later than February 1st of each year. The Chief Executive Officer will ensure that this process is completed for the Project Director. The Deputy Directors will ensure that this process is completed for all Division Directors.
The Division Directors will complete Annual Performance Evaluations for each of the Program Directors that they oversee and will also ensure that these Program Directors complete Annual Performance Evaluations for the staff that they oversee. The Quality Assurance department will review staff files during semi-annual program reviews to ensure compliance
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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.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #6 was admitted on September 14, 2023 and discharged on January 18, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This is a repeat citation from the May 22, 2022 and June 15, 2023 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility's Administrative Assistant will complete quantitative chart audits weekly to include reviewing for releases of information and review findings with the Program Director.
The Program Director will complete chart audits monthly to include reviewing for releases of information.
When issues are noted, this will be addressed individually in documented clinical supervision sessions. Any missing documentation will be completed within 24 hours.
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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 the review of client records, the facility failed to document case consultations within the timeframe established by the facility ' s policy and procedure manual in three out of seven records reviewed. The facility's policy and procedures manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety then one is completed.
Client #1 was admitted on January 5, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 5, 2024; however, it was not completed until April 15, 2024.
Client #2 was admitted on February 6, 2024 and was still active at the time of the inspection. A case consultation occurred on February 13, 2024, and the next one was due no later than May 13, 2024; however there is no documentation that one was completed.
Client #6 was admitted on September 14, 2023 and discharged on January 18, 2024. A case consultation was completed on September 29, 2023, and the next one was due no later than December 29, 2023; however, it was not completed until January 10, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all staff are trained during an in-service training on how to complete case consults in accordance with DDAP requirements and agency protocol by 7/3/24.
The Program Director will utilize a spread sheet that tracks when case consults are due. This spread sheet will be sent to staff weekly. If a case consultation is found to be late, it will be expected to be completed within 48 hours. If this is an on-going issue with a clinician, it will be addressed and documented in clinical supervision.
The facility Administrative Assistant will conduct weekly audits to include case consultations and report findings to Program Director.
The Program Director will complete monthly chart audits to include case consultations.
The Quality Assurance Manger will review for case consults during semiannual audits and report findings to the management team during the audit review meeting.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with a plan of correction that was approved by the Department.
A plan of correction for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the May 24, 2022 and June 15, 2023 annual licensing inspections. Obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was again found to be a deficiency in the May 20, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will be ultimately responsible for the implementation and compliance of all plans of correction. The Program Director will collect data from past inspections to determine how to avoid repeated citations and the best procedures for implementing a new POC. It will be the responsibility of the Program Director and the Deputy Director to ensure that future violations are not incurred in this area and that POC's are put in place. The Deputy Director will also ensure POCs are followed by meeting with Program Director to audit past and present POC procedures.
The Quality Assurance Team will audit the program semiannually to make sure that the program remains in compliance. All data gathered from the monthly and semiannual audits will be recorded. These methods will focus on the proper protocol for completing all relevant documentation.
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