INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 5/6/2015 and 5/11/2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Vantage House 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 provide documentation of individual training plans in one of three personnel records reviewed.
The findings include:
Three personnel records requiring documentation of individual training plans were reviewed at the facilities main headquarters office on 5/6/2015. The facility failed to provide documentation of an individual training plan for the January 2015 - December 2015 training year in personnel record # 3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per licensing regulations, all staff will receive an individual training plan during their annual evaluation that covers the entire year.
All new hires will receive an Orientation Training Plan within the first week of employment.
The Orientation Training Plan in question was completed on the initial date of employment for the new hire, which was 4/13/2015. Normally, the new hire orientation training plan is sent to the corporate office following the 90 day orientation period, along with the weekly supervision notes.
In order to ensure that this deficiency does not recur, the Program Director will monitor this process closely and ensure that the new hire orientation training plan is delivered to the corporate office along with all new hire documentation.
Person Responsible: Program Director
Person Responsible for the monitoring: Division Director
Full Compliance: 5/25/2015 |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all bunk beds were equipped with a securely attached railings on each open side and open end of the bunk.
The findings include:
A physical plant inspection was conducted on 5/11/2014 at approximately 2:00 PM.
The top bunk bed in Room 2, Room 12, Room 13 and Room 14 did not have railings securely attached to the open side of the bunk.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per licensing regulations, staff members will ensure that all top bunk beds have the railings securely attached on both sides of the bed. Staff will conduct hourly facility runs to ensure that the railings are in place. Staff will remind the clients of the importance of maintaining safety at all times.
Person Responsible: House Managers
Person responsible for the monitoring: Program Director
Full Compliance: 5/25/2015 |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that includes all of the required content required by regulation.
The findings include:
42 CFR, Part 2, Subpart C, subsection 2.31(a)(2) states that a consent under these regulations must include the name or title of the individual or the name of the organization to which the disclosure is made. Subpart C, subsection 2.31(a)(4) states that a consent to disclose under these regulations must include the purpose of the disclosure. 42 CFR, Part 2, Subpart C, subsection 2.31(a)(5) states that a consent to disclose under these regulations must include how much and what kind of information is to be disclosed.
Limitations imposed at 4 Pa. Code, states the following: The project may disclose information as set forth in with the consent of a client, in writing, the information to an insurance company, health, or hospital plan or facsimile thereof, which has contracted with the client to provide or will provide medical, hospital, disability or similar benefits.
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 5/11/2015. The facility failed to obtain a written informed and voluntary consent to release information to the funding source in client record # 2. Furthermore, the facility failed to document all of the required content on the informed and voluntary consent to release information forms in client records # 1, 3, 4 and 9.
Client # 1 was admitted on 12/31/2014 and discharged on 1/8/2015. Client # 1's informed and voluntary consent to release information form dated 12/29/2014 lists "referral" as the name or agency to whom the disclosure is being made.
Client # 2 was admitted on 6/13/2014 and discharged on 12/16/2014. The facility failed to obtain a written informed and voluntary consent to release information to the client's funding source.
Client # 3 was admitted on 7/25/2014 and discharged on 1/22/2015. Client # 3's informed and voluntary consent to release information to the client's funding source dated 7/25/2014 did not specify the type of information to be released.
Client # 4 was admitted on 10/21/2014 and discharged on 2/20/2015. Client # 4's informed and voluntary consent to release information to the client's significant other dated 12/30/2014 did not specify the type of information to be released.
Client # 9 was admitted on 12/11/2014 and was still an active client at the time of the inspection. Client # 9's informed and voluntary consent to release information to York County Domestic Relations dated 12/30/2014 did not specify the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per licensing regulation 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(2), all staff will ensure that the name or title of the individual or the name of the organization to which the disclosure is made, is clearly documented on each consent form.
Subpart C, subsection 2.31 (a) (4) will be adhered to, all staff will ensure that each consent form includes the purpose of the disclosure when completing the document.
Subpart C, subsection 2.31 (a) (5)all staff will ensure that all consent forms include how much and what kind of information is to be disclosed when completing the documentation.
In an effort to correct this deficiency the Administrative Coordinator has trained all staff in the proper procedure for completing consent forms. Included in the training, were completed examples for all staff to refer to.
On a monthly basis the administrative staff and the Clinical Supervisor monitors several records for the monthly Quality Improvement Meeting. During this time both the Clinical Supervisor and the Administrative Staff will ensure that all consent forms are completed in its entirety. Any deficiencies in this area will be reported to the Program Director for action of correction.
Person Responsible: Administrative Coordinator
Person responsible for the monitoring:
Program Director
Full Compliance: 5/25/2015 |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a complete physical examination upon intake in five of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a physical examination were reviewed on 5/11/2015. The facility failed to document a complete physical examination that includes client vital signs in client records # 2, 4, 5, 9 and 10.
Client # 2 was admitted on 6/13/2014. Documentation of the client's physical examination dated 6/18/2014 did not include the client's vital signs.
Client # 4 was admitted on 10/21/2014. Documentation of the client's physical examination dated 10/22/2014 did not include the client's vital signs.
Client # 5 was admitted on 11/26/2014. The client's physical examination was completed on 12/11/2014.
Client # 9 was admitted on 12/11/2014. Documentation of the client's physical examination dated 12/17/2014 did not include the client's vital signs.
Client # 10 was admitted on 2/11/2015. Documentation of the client's physical examination dated 2/18/2015 did not include the client's vital signs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per licensing regulations, staff will ensure that all clients receive a completed physical examination including vital signs within the admission process.
The facility nurse will schedule all physical examinations for all the newly admitted clients within 72 hours of admission. Additionally, the facility nurse will ensure that all new clients participate and receive in a full physical that includes vital signs within the first 7 days of admission.
In an effort to ensure that this deficiency does not recur, the nurse will inform the Program Director of all scheduled physicals for all new admissions within the 72 hour time frame. Additionally, the nurse will ensure that the vital signs are recorded on each physical. The Program Director will monitor this action with all new admits.
Person responsible: Nurse
Person responsible for the monitoring: Program Director
Full compliance: 5/25/2015 |
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 a review of client records, the facility failed to document a treatment plan update at least every 30 days in three of nine client records reviewed.
The findings include:
Nine client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 5/15/2015. The facility failed to document a treatment plan update at least every 30 days in client records # 2, 6 and 8.
Client # 2 was admitted on 6/13/2014 and discharged on 12/16/2014. The last two treatment plan updates for the client were completed on 10/9/2014 and 11/19/2014.
Client # 6 was admitted on 8/25/2014 and discharged on 1/26/2015. The client's initial treatment plan was completed on 8/28/2014. There was no documentation of a treatment plan update for September 2014 and October 2014.
Client # 8 was admitted on 2/5/2015 and was still an active client at the time of the inspection. The last two treatment plan updates for the client were completed on 4/2/2015 and 5/9/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per licensing regulations, all counselors will ensure that each initial treatment plan, and all updated treatment plans are completed within the allotted time frame. Initial treatment plans will be completed within 5 days of the clients admission, and all updated treatment plans will be completed within the 30 day period, with the clients input.
In an effort to ensure that this deficiency does not recur, the Clinical Supervisor will review and sign all treatment plans. During this review, the Clinical Supervisor will check for accurate documentation, and address any deficiencies with the clinical staff member for corrections. Additionally, the Clinical Supervisor will ensure that all treatment plans are completed within the allotted time frame. During the weekly clinical meeting the Clinical Supervisor will update and hand out a form with all clients names, assigned counselors and specific dates that identify the due date for each treatment plan.
Person Responsible: Clinical Supervisor
Person responsible for the monitoring: Program Director
Full Compliance: 5/25/2015 |
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 client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in three of ten client records reviewed.
The findings include:
Ten client records were reviewed for counseling services on 5/11/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 2, 6 and 7.
Client record # 2 contained a treatment plan dated 11/19/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client in the entire months of November 2014 and December 2014.
Client record # 6 contained a treatment plan dated 12/18/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. The only individual therapy session scheduled for the client in January 2015 was on 1/7/2015.
Client record # 7 contained a treatment plan dated 3/16/2015 that identified the counseling services to be provided as individual therapy sessions 2 times per week. The only individual therapy sessions scheduled for the client in March 2015 through April 2015 were 3/20/2015, 3/31/2015, 4/7/2015 and 4/15/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As per licensing regulations, all counselors will ensure that the provision of services indicated in each treatment plan is provided on the monthly basis. All individual sessions will be completed, documented and reviewed by the Clinical Supervisor within the allotted time frame.
Person responsible: Clinical Supervisor
Person responsible for monitoring: Program Director
Full Compliance: 5/25/2015
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