INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26-27, 2010 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 June 19, 2010.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the personnel training records, facility policies and procedures and an interview with the Training Manager, the facility failed to document feedback on completed training in two of three personnel records.
The findings include:
Seven personnel training records were reviewed on May 7, 2010. Of the seven records reviewed, three contained documentation of training completed during the 2009 training year., but feedback on the completed training was not included in records # 2 and 3.
The facility ' s policy titled " PLAN FOR COLLECTION OF FEEDBACK ON STAFF TRAINING " states:
" Each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/ Clinical Supervisor. "
An interview with the Training Manager on May 7, 2010 confirmed that personnel training records #2 and 3 did not contain Staff Training Reports.
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Plan of Correction
In ensuring that the Training Feedback is in the Corperate Personnel charts the following steps will be followed. The Program Supervisor will conduct an In Service Training on the Feedback Training policy.
The Administrator Coordinator will monitor after each training by calling the Corporate Training Institute to follow up that the procedure was followed.
The Program Supervisor will monitor and conduct random audits on the Personnel charts on monthly bases to ensure the completeness of the records at the facility and at the Corporate Office
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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 training records, facility policies and procedures and an interview with the Training Manager, the facility failed to provide documentation of HIV/AIDS and TB/STD training in one of five personnel training records as per facility policies and procedures.
The findings include:
Facility policy titled, Standard: 704.11.c Subject: General Training dated January, 2009 stated:
Core staff training shall be completed within the first three months of employment and
include, but not be limited to:
DOC - Orientation - first 40 hours as per American Corrections Association standards
HIV/AIDS - 6 hours for counselors orientation period
TB/STDS - 4 hours for counselors within three months of employment and other staff
within two years
Fire Safety - [do a preliminary review the first week]
CPR - orientation period
Seven personnel training records were reviewed on May 7, 2010. Of the seven records reviewed, five were required to have documentation of HIV/AIDS and TB/STD training per facility policy. The facility did not provide documentation of HIV/AIDS and TB/STD training in personnel training record # 4.
Employee #4 is a clinical supervisor and was hired on November 19, 2007. TB/STD training was due to be completed no later than November 19, 2009. As of the date of inspection the facility did not provide documentation of HIV/AIDS and TB/STD training for employee #4.
An interview with the Training Manager on May 7, 2010 confirmed that employee #4 did not have documentation of HIV/AIDS and TB/STD training.
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Plan of Correction
The Personnel #4 had their HIV/AIDS in their facility 8/20/08. The TB/STD training was completed on 2/27/2008. Copies of both certificates were sent to the Training Institute.
To ensure compliance, a copy of each training certificate will be placed in the Corporate personnel record by the Administrative Coordinator. The Admin. Coord. will make a copy of each training certificate and fax them to the Training Institute.
On a monthly bases
The Program Supervisor and Administrative Coordinator will follow up by conducting random audits of the personnel records with the Human Resources Department at the facility and the Corporate Office.
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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 a review of CPR certification records and a review of the staff schedule, 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:
CPR certification records and the staff schedule were reviewed on May 27, 2010. 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 8:00 AM to 4:00 PM (weekends), the 4:00 PM to 12:00 AM shift, and the 12:00 AM to 8:00 AM shift.
During the month of May, the facility did not have at least one person certified in CPR on the 8:00 AM to 4:00 PM shift on May 2, 16, 22 and 23.
During the month of May, the facility did not have at least one person certified in CPR on the 4:00 PM to 12:00 AM shift on May 5, 6, 12, 13, 20, 21, 22, 23 and 27.
During the month of May, the facility did not have at least one person certified in CPR on the 12:00 AM to 8:00 AM shift on May 15.
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Plan of Correction
The Program Supervisor will audit the personnel records during the staff monthly Supervision to ensure that the CPR certifications and other Core trainings are completed.
The Administrative Coordinator will start with completing monthly audits of the CPR and other Core trainings. The Administrative Coordinator will make a copy of the CPR certifications and fax them to the Corporate office to be placed in the staff personnel record.
The Program Supervisor and Administrative Coordinator will conduct random audits at the Corporate Office to ensure compliance monthly.
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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 the review of personnel training records and an interview with the Training Manager, the facility failed to document at least 12 clock hours of training annually for each facility director in one of one records.
The findings include:
Seven personnel training records were reviewed on May 7, 2010. Of the seven records reviewed, one was a facility director and required at least 12 clock hours of training for the 2009 training year. The facility did not document at least 12 hours of training for personnel #2. The training record for personnel #2 contained 4 hours of training for the 2009 training year.
An interview with the training Manager was conducted on May 7, 2010. The Training Manager confirmed that the training record for personnel #2 contained only 4 hours of training.
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Plan of Correction
Staff member #2 had the following trainings in 2009:
City of Philadelphia Fire & Safety Prevention. Recovery Management in a Therapeutic Community, City of Philadelphia Compliance Training,
Office of Mental Health Treatment Planning. These certificates were faxed to the Corporate Office.
To ensure the training certificates are in the staff records at the Corporate Office, the Administrative Coordinator will obtain a copy of the training certificates from each staff member. The Administrative Coordinator will then fax a copy of each certificate to the Corporate office to be filed.
The Program Supervisor and Administrative Coordinator will conduct random audits at the Corporate Office to ensure compliance monthly.
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel training records and an interview with the Training Manager, the facility failed to document at least 12 clock hours of training annually for each clinical supervisor in two of two records.
The findings include:
Seven personnel training records were reviewed on May 7, 2010. Of the seven records reviewed, two were clinical supervisors and required at least 12 clock hours of training for the 2009 training year. The facility did not document at least 12 hours of training for personnel #s 3 and 4.
The training record for personnel #3 contained 4 hours of training for the 2009 training year.
The training record for personnel #4 contained 0 hours of training for the 2009 training year.
An interview with the training Manager was conducted on May 7, 2010. The Training Manager confirmed that the training records for personnel #s 3 and 4 did not contain at least 12 hours of training for the 2009 training year.
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Plan of Correction
Staff member #3 and #4 had Record Keeping on March 12th and 13th of 2009. This training consisted of 8 CEU hours each. The Administrative Coordinator faxed a copy of the training certificates to the Corporate Office to be placed in the personnel records.
To ensure the training certificates are in the staff records at the Corporate Office, the Administrative Coordinator will obtain a copy of the training certificates from each staff member.
The Administrative Coordinator will then fax a copy of each certificate to the Corporate office to be filed.
The Program Supervisor and Administrative Coordinator will conduct random audits at the Corporate Office to ensure compliance monthly.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel training records and an interview with the Training Manager, the facility failed to document that fire extinguisher training was provided upon employment in one of seven records.
The findings include:
Seven personnel training records were reviewed on May 7, 2010. All seven records required documentation that fire extinguisher training was provided upon employment. The facility did not document that fire extinguisher training was provided upon employment in personnel record #6.
Personnel #6 was hired on 2/1/10, but verification of this training was not documented at the time of review on 5/7/10.
An interview with the Training Manager on May 7, 2010 confirmed that personnel training records #6 did not contain documentation of fire extinguisher training.
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Plan of Correction
Staff member #6 received Fire and Safety training on March 15th 2010. A copy of #6 training certificate was pulled from the facility personnel record and faxed to the Corporate office.
To ensure the training certificates are in the staff records at the Corporate Office, the Administrative Coordinator will obtain a copy of the training certificates from each staff member. The Administrative Coordinator will then fax a copy of each certificate to the Corporate office to be filed.
The Program Supervisor and Administrative Coordinator will conduct random audits at the Corporate Office to ensure compliance monthly.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the review of personnel training records and an interview with the Training Manager, the facility failed to document that all personnel are trained to perform assigned task during emergencies in one of seven personnel records reviewed.
The findings include:
Seven personnel training records were reviewed on May 7, 2010. All seven records required documentation that emergency training was provided upon employment. The facility did not document that emergency training was provided upon employment in personnel record #6.
Personnel #6 was hired on 2/1/10, but verification of this training was not documented at the time of review on 5/7/10.
An interview with the Training Manager on May 7, 2010 confirmed that personnel training records #6 did not contain documentation of emergency training.
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Plan of Correction
Staff member #6 received Fire and Safety training on March 15th 2010. During the Fire and Safety training the emergency evacuation was reviewed and a Fire Drill was conducted by the City of Philadelphia Fire Department. A copy of #6 training certificate was pulled from the facility personnel record and faxed to the Corporate office.
To ensure the training certificates are in the staff records at the Corporate Office, the Administrative Coordinator will obtain a copy of the training certificates from each staff member. The Administrative Coordinator will then fax a copy of each certificate to the Corporate office to be filed.
The Program Supervisor and Administrative Coordinator will conduct random audits at the Corporate Office to ensure compliance monthly.
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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 the review of client records, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in three of eight client records.
The findings include:
Eight client records were reviewed on May 26-27, 2010. All eight records required documentation of type and frequency of treatment and rehabilitation services. The facility did not document a treatment plan to include type and frequency of treatment services, as per facility policy, in client records # 1, 2, and 7.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" 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. "
In client record #1, the treatment plan documented on 12/3/09 did not include type and frequency of treatment and rehabilitation services.
In client record #2, the treatment plan documented on 2/8/10 did not include type and frequency of treatment and rehabilitation services.
In client record #7, the treatment plan documented on 1/26/10 did not include type and frequency of treatment and rehabilitation services.
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Plan of Correction
Plan of Correction:
The Clinical Program Supervisor will conduct a Clinical In-service training on the documentation to always include the type and frequency on the treatment plans.
During the weekly Treatment Team the Clinical Supervisor will audit the clinical charts to review the compliance of the treatment plans and its frequency to ensure compliance. During Supervision the Supervisors will review with the clinical staff the documentation of the type and frequency in the treatment plans. The Director will conduct random audits of clinical charts to monitor the documentation of the type and frequency is on each treatment plan monthly
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to document a treatment plan update in eight of eight client records.
The findings include:
Eight client records were reviewed on May 19-20, 2010. All eight records required a treatment plan update. The facility did not document a treatment plan update, as per facility policy, in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
The facility ' s policy titled " Treatment Plan Reviews " states:
The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted.
In client record #1, the treatment plan updates documented on 12/30/09, 1/28/10, 2/25/10, 3/30/10 and 5/20/10 did not include an assessment of progress.
In client record #2, the treatment plan updates documented on 3/8/10 and 4/8/10 did not include an assessment of progress.
In client record #3, the treatment plan updates documented on 3/25/10 and 5/20/10 did not include an assessment of progress.
In client record #4, the treatment plan update documented on 3/30/10 did not include an assessment of progress.
In client record #5, the treatment plan updates documented on 4/22/10 and 5/19/10 did not include an assessment of progress.
In client record #6, the treatment plan updates documented on 4/13/10 and 5/11/10 did not include an assessment of progress.
In client record #7, the treatment plan updates documented on 2/24/10 and 3/23/10 did not include an assessment of progress.
In client record #8, the treatment plan updates documented on 2/11/10, 3/11/10 and 4/8/10 did not include an assessment of progress.
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Plan of Correction
Plan of Correction:
The Clinical Program Supervisors will Conduct an In-Service training to review the documentation of the assessment of progress on each goal.
During the Treatment Team the Clinical Program Supervisor will audit the clinical charts to ensure the documentation of the assessment of progress is completed. When not completed the Supervisor will give the chart to the Counselor for correction. Once corrected the Counselor will return the clinical chart back to the Supervisor for review.
The Program Director will monitor the clinical charts weekly for compliance. After 3months of compliance the Director will monitor on a quarterly bases to ensure the assessment of progress is documented.
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