INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on May 31, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in two out of four records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, personnel records for employees # 1, 2, 3 and 4 were reviewed. The project failed to develop an individual training plan annually in accordance with policy for personnel #s 1 and 3.
Employee # 1 has been the Project Director since 1988. The facility failed to document an individual training plan in January for employee # 1. Personnel # 1's record did not contain a training plan.
Employee # 3 has been the clinical supervisor since 2009. The facility failed to document an individual training plan in January for employee # 3. The training plan in personnel # 3's record was dated 7/10/11
The findings were reviewed with the human resources staff.
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Plan of Correction
The training department will ensure that an individual training plan is developed and documented with all employees within required timeframes. This will be completed for all employees by January 31st, 2013 as per our policy.
The Project Director's Individual Training Plan was completed on May 9, 2012. The Training Institute will insure that the Project Director's Training Plan is done by January 31 of each year. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
An inspection of the facility's physical plant was conducted on May 31, 2012 between approximately 1:30 PM and 2:15 PM. The grounds of the facility were not in good repair at the time of inspection.
The carpets were soiled in client bedrooms # 0, 1, 2, 4, 5, 6, 7, 8, 10, 11 and 12.
The clinical supervisor was present during the physical plant inspection and confirmed the findings.
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Plan of Correction
Program Director will submit a request for new carpeting or carpet cleaning. Program Director will submit monthly report to Division Director on status of request. After 6 months if no action has been taken, Program Director will ask for review by Eastern Regional Director. |
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, the facility failed to store all trash, garbage and rubbish in covered containers.
The findings include:
An inspection of the facility's physical plant was conducted on May 31, 2012 between approximately 1:30 PM and 2:15 PM. At the time of inspection, the trash dumpsters were overflowing with trash. The dumpster's lids could not be closed due to the excessive amounts of trash in the dumpster. This allowed for the potential infestation of insects, rodents and other animals.
It should be noted that the trash dumpsters were located within the children's outdoor play area.
The clinical supervisor was present during the physical plant inspection and confirmed the findings.
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Plan of Correction
Program Director bought a metal 30 gallon trash can for overflow in the future. Dumpster lids will be checked daily at trash runs which occur 3x per day. This is performed by House Managers. Director will check daily for next 90 days to insure compliance. |
705.11 (1) (i) LICENSURE Child care.
705.11. Child care.
When a residential facility admits children for services or for custodial care, the following requirements apply:
(1) Building exterior and grounds. The residential facility shall:
(i) Fence off or have natural barriers to protect children from all areas determined to be unsafe including steep grades, cliffs, open pits, swimming pools, high voltage boosters or roads.
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Observations
Based on a physical plant inspection, the facility failed to fence off or have natural barriers to protect children from all areas determined to be unsafe including steep grades, open pits, swimming pools, high voltage boosters or roads.
The findings include:
An inspection of the facility's physical plant was conducted on May 31, 2012 between approximately 1:30 PM and 2:15 PM. The the facility failed to fence off or have natural barriers to protect children from all areas determined to be unsafe at the time of inspection.
At the time of inspection, the trash dumpsters were located within the children's outdoor play area. The dumpsters were overflowing with trash to the point that the lids could not be closed. This allowed for the potential infestation of insects, rodents and other animals.
There was a gap between the large gates of the children's outdoor play area that would allow for a small child to exit the play area and access the road immediately adjacent to the play area.
There were 24 grey partitions leaning against the fence in the children's outdoor play area that presented a hazard where a child could crawl in-between them and the partitions could fall on the child.
The clinical supervisor was present during the physical plant inspection and aware of the findings.
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Plan of Correction
Dumpsters being too full has been addressed. See PO13.
Grey boards will be removed by maitenance by July 2, 2012. Program Director will insure work is done.
The Program Director and Maitenance have determined that a four foot fence can be installed from the back steps to the fence that will block off the dumpsters from the play area. fence will have a small gate that will be child proof for access by the residents to the dumpsters. Work will be completed by 8/15/12 and a photo submitted by 8/15/12/
Until the time that the fence is comleted, the children can play at the playground that is located on the far side of Tioga Arms (Gaudenzia Housing Program). Children are monitored at all times by the mothers and/or child care staff while at the playground. A photo of the playground will be submitted by 7/19/12. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based on a physical plant inspection, the facility failed to maintain security screens or safety locks for all operable windows.
The findings include:
An inspection of the facility's physical plant was conducted on May 31, 2012 between approximately 1:30 PM and 2:15 PM. The facility was required to maintain security screens or safety locks for all operable windows. The facility did not have security screens or safety locks for all operable windows on the second and third floors.
At the time of inspection, the windows in client bedrooms # 8 and 11, on the second floor, did not have security screens or safety locks.
At the time of inspection, the windows in the third floor girls' bathroom and the third floor boys' bathroom did not have security screens or safety locks.
The clinical supervisor was present during the physical plant inspection and confirmed the findings.
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Plan of Correction
Windows were secured by maintenance on June 1, 2012. Weekly inspections of windows will occur. Program Director has instituted an internal safety committee who will check the windows on a weekly basis and report out in weekly staff meeting.
Program Director and/or Clinical Supervisor will inspect windows monthly for compliance. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, the facility failed to maintain protective caps over each electrical outlet in areas designated for children.
The findings include:
An inspection of the facility's physical plant was conducted on May 31, 2012 between approximately 1:30 PM and 2:15 PM. The facility was required to maintain protective caps over each electrical outlet in areas designated for children.
At the time of inspection, client bedrooms # 0, 1, 2, 8, 11 and 12 did not have protective caps over the electrical outlets.
The clinical supervisor was present during the physical plant inspection and confirmed the findings.
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Plan of Correction
Program Director replaced all outlet covers on May 31, 2012. Program Director instituted an internal safety committee who will insure compliance and report out weekly in staff meeting.
Runs on outlet covers will occur during daily fire runs which occur 3x per day by house managers.
Program Director and Clinical Supervisor will check monthly to insure compliance. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of the project ' s Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, 'Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client ' s psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..." The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant po;icies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvment Director to ensure consistency and clarity and to meet all relevant State, Accreditation, and Funder requirements. Changes to these policies will be communicated to clinicians at each facilities staff meetings by the Program Director and/or Supervisor.
The relevant policies in the Gaudenzia Policy & Procedure Manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis. These policies will be revised and approved by July 31, 2012. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within the required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner. The meeting was held on 4/30/12. The Financial Audit for Fiscal Year 2011-2012 will be completed within 6 months after June 30th close of Gaudenzia's fiscal year (by December 31st, 2012) as per Chapter 709.25 (a). |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary in one out of two records.
The findings include:
On May 31, 2012, two client records requiring a discharge summary were reviewed, specifically records # 6 and 7. The facility did not document a discharge summary in client record # 6.
Client # 6 was admitted on 11/25/11 and discharged on 2/15/12. Client # 5's record did not contain a discharge summary.
The clinical supervisor confirmed the findings.
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Plan of Correction
When a client leaves, a complete chart check is done for CQI compliance. If all required documentation is not in the chart, the chart is not closed. The chart is then given to the Administrative Coordinator for storage. Charts that need to be removed from storage will not be taken out of the Administrator's office. Before the chart is returned to the storage cabinent, the Coordinator will do a chart check for compliance. |