INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 9 - 10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia, Inc. 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(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual on May 21 - 24, 2019, the facility failed to follow their policy in regards to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection on July 10, 2019, it was observed that the facility failed to have slip-resistant surfaces in all bathtubs and showers. There was no slip-resistant mat located in the shower in the female detoxification unit bathroom.
The findings were reviewed with facility staff.
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Plan of Correction
The non slip mat was replaced on 7/12/2019 and this is added to the shift Sanitation and Safety Inspection that is performed each shift in order to ensure that they remain. |
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
Based on a physical plant inspection on July 10, 2019 at approximately 2:30pm, the facility's outside refrigerator temperature registered at 43 degrees. Regulations states cold food must be kept at or below 40 degrees.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A maintenance ticket was placed on 7/10/19 and the maintenance work order has been completed. Kitchen staff will monitor the temperature each shift and report any abnormality to Program/Division Director immediately. |
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 a review of personnel files on June 3, 2019, employee #1 was not trained in fire extinguisher use upon hire. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation that the employee received the training as of the date of this inspection July 9 - 10, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
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 upon a review of personnel files on June 3, 2019, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1 ' s personnel file indicating that the employee had been trained on what to do during emergencies as of the date of this inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (d) (3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of twenty-one client records on July 9-10, 2019, the facility's client's rights documentation, which is included in the client's paper record, failed to include all the required client rights, including that facility staff may limit access to their records if determined to be detrimental, and reason for removing sections of record shall be documented. The documentation was missing in all twenty-one client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The updated Client Rights Form was provided to all active residents in paper form on 7/10/2019 and placed into the Client Handbook.
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of twenty-one client records on July 9-10, 2019, the facility's client's rights documentation, which is included in the client's paper record, failed to include all the required client rights, including that the client's right to appeal a decision limiting access to their records. The documentation was missing in all twenty-one client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of twenty-one client records on July 9-10, 2019, the facility's client's rights documentation, which is included in the client's paper record, failed to include all the required client rights, including that the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record. The documentation was missing in all twenty-one client records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
715.1(a)(b) LICENSURE General Provisions
(a) An entity within this Commonwealth which uses agents for maintenance or detoxification of persons shall obtain the approval of the Department to operate a narcotic treatment program.
(b) The Department's approval of a narcotic treatment program shall be contingent upon the narcotic treatment program's compliance with the standards and conditions in this part. In addition, the program shall comply with applicable Federal laws and regulations.
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Observations
Based on an annual inspection conducted on July 9-10, 2019, the facility failed to ensure compliance with applicable federal standards and conditions. At the time of the inspection, the facility was unable to provide documentation of current Drug Enforcement Administration (DEA) cards indicating approval to prescribe buprenorphine for the medical director and the nurse practitioner.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All updated DEA cards forwarded via email on 8/1/2019. The Nurse Manager will keep accurate records of all prescribing physicians in the Nursing station and review monthly for accuracy. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the project's policy and procedure manual on May 21- 24, 2019, the project's grievance procedure does not address permitting patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director.
Based on a review of the project's policy and procedure manual on May 21 - 24, 2019, the project's grievance procedure does not address grievances filed by patients against the narcotic treatment program director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Grievance Procedure to accurately reflect the DDAP 715.22 regulations regarding a client's right to file a grievance. The document now indicates that, clients are ensured a full and fair opportunity to be heard, to question and confront persons and evidence used against them, and to have a fair review of their grievances by the narcotic treatment program director. Grievances filed by clients against the narcotic treatment program director will be heard by the Division Director, Regional or Deputy Regional Director, and/or the Corporate Compliance Officer. This revised Policy will be distributed to all programs by 8/9/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/30/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the orientation manual is being completed. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven inpatient rehabilitation client records on July 9-10, 2019, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four records reviewed.
Client #8 was admitted on June 4, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated June 5, 2019, indicated weekly individual sessions. The record of service and progress notes indicated that the client did not receive any individual sessions between June 10 - 23, and June 25 - July 7, 2019.
Client #11 was admitted on January 7, 2019 and discharged on March 13, 2019. The comprehensive treatment plan, dated January 8, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client's last individual session prior to discharge was on February 27, 2019.
Client #13 was admitted on April 23, 2019 and discharged on May 16, 2019. The comprehensive treatment plan, dated April 24, 2019, indicated weekly individual sessions. The record of service and progress notes indicated that the client did not receive any individual sessions between April 28 - May 12, 2019.
Client #14 was admitted on December 3, 2018 and discharged on March 13, 2019. The comprehensive treatment plan, dated December 5, 2018, indicated weekly individual sessions. The record of service and progress notes indicated that the client did not receive any individual sessions between December 14, 2018 - January 16, 2019. In addition, the client's last individual session prior to discharge was January 25, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical staff completed an In-service with Division Director on 7/11/2019 reviewing utilization of the treatment plan and correlating documentation. Ongoing monitoring of documentation will be performed by the Division/Program Director to ensure accuracy. |