INITIAL COMMENTS
|
This report is a result of an unannounced follow-up inspection conducted on February 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure for the complaint investigation of July 27 & 28, 2010. Based on the findings of the on-site inspection, Gadenzia, INC. West Chester 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 April 23, 2011.
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of five personnel records on February 7, 2011, the facility failed to ensure that each counselor met the qualifications for the position as required.
Findings:
On February 7, 2011 five personnel records were reviewed to ensure that staff met the qualifications for their position. One out of five records reviewed, specifically record # 2, lacked documentation to verify that employee # 2 met the educational requirements for the position of a Counselor.
Personnel record # 2 contained documentation of a Bachelors of Arts diploma; however, the major was not identified and there were no transcripts to verify what major the degree was for.
|
Plan of Correction
When looking at the selected personnel file that was cited in the inspection on February 7, 2011, the Program Director had spoken with University that degree was from to verify that degree was in Sociology. However, that conversation was not noted in the individual's personnel folder.
GHWC has since followed up with the academic institution and retrieved the transcripts and verified that this counselor's degree is in Sociology, which would satisfy the required qualifications for the counselor position and faxed them over to the Licensing Supervisor the day that the citation was noted, 2/7/2011.
Finally, in order to prevent this citation from occurring in the future, Managerial Staff, as well as, Program Director will request the necessary information (transcripts, diplomas, and etc.) at the time of the interview process. Furthermore, it will be clearly documented within the individual's personnel folder that these documents have been reviewed by GHWC Managerial Staff/Program Director to prevent this citation from reoccurring.
|
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.
|
Observations
Based on observation during the physical plant inspection that was conducted on February 7, 2011, 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 the residents, employees and visitors.
The findings include:
On February 7, 2011 a physical plant inspection was conducted from approximately 1:30 PM to 2:30 PM. The facility's House Manager accompanied the Licensing Specialists on this physical plant inspection.
There were holes in the ceiling in several locations in the room labeled as the "Philly Room" .
This is a repeat deficiency from July 28, 2010.
There was plaster on the floor underneath the holes in the ceiling of the room labeled as the "Philly Room".
This is a repeat deficiency from July 28, 2010.
The door on the right side of the first closet in the "Philly Room" was missing.
The blinds on the window of the "Philly Room"were not in operating order and could not be closed more than half way.
There was a wire with tape around it hanging from the ceiling of the basement weight room. This wire continued out the window and connected to an outside electrical box.
There was plaster missing and peeling from the wall above the window of the basement weight room.
Bathroom"A" had the handle missing from the bath tub and the shower. The men had to travel down the hall to wash. The House Manager confirmed the tub and shower would need to be fixed.
|
Plan of Correction
GHWC has identified the Program Supervisor and a House Manager to visually inspect the facility on a daily basis. During that visual inspection of the facility, any maintenance issues that are found will be notated and inputted into the agency maintenance system.
When maintenance issues of a serious nature were to occur, Program Supervisor will communicate the magnitude of the concern to the Program Director and Property Manager and/or his designee to ensure that work is began/completed immediately.
Depending on the severity of the issue, House Manager and/or Program Supervisor will ensure the issue is rectified within a 30 day timeframe by following up with Program Director, and/or any other parties within the Maintenance Department.
Program Supervisor will also implement a follow measure with the identified maintenance concern. One week after submission of maintenance request, Program Supervisor will document whether or not identified concern has been completed or the status of the project (contractors hired, parts ordered, etc). Program Supervisor will continue to follow up with abovementioned parties to ultimately ensure that maintenance concerns are addressed within 30 days that the concern was originally noted.
Finally, in looking at the identified concerns, Program Supervisor has re-inputted maintenance concerns in the maintenance and will begin to follow up with the abovementioned procedure to ensure that these issues are rectified by May 15, 2011. In addition to that, Program Supervisor will continue to communicate all physical plant issues, address and/or unaddressed in weekly management meetings to ensure adequate follow up and follow through. Therefore, decreasing and/or eliminating this citation from reoccurring.
When looking at each of the identified areas of concerns the following actions have/will be taken:
- There were holes in the ceiling in several locations in the room labeled as the "Philly Room".
The identified holes in the ceiling were fixed on the 2nd of March, 2011 by the Property Manager and/or his designee.
- There was plaster on the floor underneath the holes in the ceiling of the room labeled as the "Philly Room".
The plaster that was noted underneath the holes of the ceiling was cleaned up by the Program Supervisor and House Manager on Duty on the 7th of February.
- The door on the right side of the first closet in the "Philly Room" was missing.
The missing door of this client has been ordered by the Program Supervisor/Property Manager on the 21st of April, The door is currently on order and will be installed by the Property Manager once received on or before the 15th of May.
- The blinds on the window of the "Philly Room" were not in operating order and could not be closed more than half way.
Measurements for the inoperable blinds in the "Philly Dorm" were taken by the Program Supervisor and the ordered was placed on the 21st of April. The blinds are currently on order and will be installed by the Property Manager and/or his designee once received on or before the 15th of May.
- There was a wire with tape around it hanging from the ceiling of the basement weight room. This wire continued out the window and connected to an outside electrical box.
On the 8th of February, the Property Manager and the Program Supervisor assessed the abovementioned wire. Property Manager ordered a contract worker with Electrical expertise to appropriately and professionally secure the wire. On the 10th of February, the Property Manager and Contracted Electrician secured the wire and rerouted the connection that was identified to travel out the window to a more secure location and hidden from plain sight/exposure.
- There was plaster missing and peeling from the wall above the window of the basement weight room.
On the 9th of February, Property Manager removed old molding and plaster from this window and replaced the molding, plaster, and paint around this window.
- Bathroom "A" had the handle missing from the bath tub and the shower. The men had to travel down the hall to wash. The House Manager confirmed the tub and shower would need to be fixed.
On the 14th of February, the Property Manager and Program Supervisor placed an order for this handle. When the part was retrieved on the 22nd of February, Property Manager and/or his designees replaced the missing handle on the 23rd of February.
|
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
|
Observations
Based on observation during a physical plant inspection on February 7, 2011 , the facility failed to provide toilet paper at each toilet at all times.
The findings include:
On February 7, 2011 a physical plant inspection was conducted at approximately 1:30 PM.
The Facility Director and House Manager accompanied the Licensing Specialists.
The previous citation for both toilet stalls in Bathroom A on the second floor in the men's wing missing toilet paper was corrected; however, during the inspection, the first stall in the male bathroom located in the basement was without toilet paper.
|
Plan of Correction
Since the site visit, GHWC has maintained a Program Supervisor and a House Manager to oversee the quantity and order of supplies.
Supplies House Manager will monitor household supplies, which include toilet paper, and order the needed/necessary quantities on a biweekly basis.
In addition to acquiring this House Manager to oversee this aspect of the program, all House Managers and clients in the facility have and continue to be taught/trained on completing multiple checks of the facility, which includes the restrooms, to ensure adequate supplies are present at all times. If area were to be found to be missing an essential item, request for these supplies will be noted and given to the proper party to ensure adequate follow through and follow up.
|
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant tour on February 7, 2011, and an interview, the facility failed to ensure that there were no heaters that are not permanently mounted or installed.
The findings include:
On February 7, 2011 a physical plant inspection was conducted at approximately 1:30 PM.
The facility had a heater that was not permanently mounted or installed located in counselor room #1 located in the basement. The House Manager confirmed that there was a heater in the room and that it failed to comply with regulations.
|
Plan of Correction
On the day of the site visit, the portable heater that was noted in this citation was properly disposed of in the trash as it was inoperable at the time of the visit.
However, on that day, February 7, 2011, it was determined that an in-service training would be held at the next scheduled General Staff Meeting.
On the 1st of March, the Program Supervisor/Director facilitated an in-service training with all the staff of GHWC to inform them and reiterate the program's established protocol in regards to portable heaters. That protocol explicitly states that these devices, portable heater that are not permanently mounted, are not permitted on the property of GHWC at any time.
Finally, the Program Supervisor is the identified person within the facility to ensure that there are no portable heating devices in any area of the facility. This will be done on a daily basis by Program Supervisor to ensure compliance and prevent reoccurrence of citation.
|
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
Based on an onsite follow-up inspection on February 7, 2011, the facility failed to ensure that all exits were unobstructed.
The findings include:
On February 7, 2011 a physical plant inspection was conducted at approximately 1:30 PM. During the physical plant inspection it was noted that the second floor exit from room #4 on the female wing was obstructed by snow that had not been cleared way.
|
Plan of Correction
Since the site visit, the snow has been removed. In the event of a snow storm, GHWC will ensure that this exit and all other exits are free and clear of any obstructions. |