INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2012 and November 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gratitude House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 and training records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in two of seven personnel records. The findings include:Seven personnel records were reviewed on October 2-3, 2012. Eight personnel records required documentation of HIV/AIDS and/or tuberculosis, sexually transmitted diseases and other health related topics training. Employee records # 6 and 7 did not include documentation of the completion of the required training. Employee # 6 was hired on September 8, 2009. Tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by September 8, 2011. There was no documentation that the employee had completed the TB/STD training as of October 5, 2012. Employee # 7 was hired on October 7, 2008. Tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by October 7, 2010. There was no documentation that the employee had completed the TB/STD training as of October 5, 2012. The human resource staff was interviewed on October 3, 2012 and confirmed the findings.
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Plan of Correction
Facility director will ensure employees #6 & #7 attend the next scheduled TB/STD training on 11/27/2012 at Pyramid's Corporate training room. Facility director will follow-up with Human Resource Coordinator and employees after said training date to ensure attendance. Human Resource Coordinators will monitor employee files quarterly to ensure compliance regarding mandatory trainings. |
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 a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director and the facility director in one of two personnel records.The findings include:Fifteen personnel records were reviewed on October 2-3, 2012. The facility's training year is January- December. The facility's 2011 training year was reviewed. Two personnel records required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1. Employee # 1 has been the project director since July, 1999. There were no training hours documented for the 2011 training year. The human resource staff was interviewed on October 3, 2012 and confirmed the findings.
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Plan of Correction
Employee #1, Project Director, will complete 12 hours of training by November 30, 2012. Human Resource Coordinator will ensure completion. Human Resource Coordinators will monitor training compliance via quarterly reviews of employee files, to include Project Director. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three personnel records.The findings include:Seven personnel records were reviewed on October 4-5, 2012. Seven personnel records pertained to counselors. Three personnel records were required to include documentation of the completion of 25 clock hours of annual training. The facility's training year is from January through December. The facility's 2011 training year was reviewed. The facility failed to document 25 clock hours of annual training in personnel record # 4.Employee # 4 was hired on August 22, 2005 and promoted to counselor position on July 16, 2007. Employee # 4 had only 0 clock hours of training documented for the 2011 training year. The Facility Director was interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Facility Director will meet with Employee #4 to discuss training requirements and timelines to complete. Employee #4 will be instructed to complete the required 25 hours by 12/31/2012. Facility director will follow-up with Human Resource Coordnator to ensure compliance. Human Resource Coordinators will monitor training compliance via quarterly employee file audits.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill record, the facility failed to conduct a fire drill during sleeping hours at least once every six months.The findings include:The fire drill record was reviewed on October 31, 2012. Documentation of a fire drill conducted during sleeping hours is required once every six months. The fire drill record was reviewed from November 2011 to October 2012. During that time frame, the facility documented only two fire drills during sleeping hours, March 2012 and October 2012. The last overnight drill, October 2012, was documented 7 months after the March 2012 fire drill. An interview with the facility director on November 1, 2012 confirmed the findings.
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Plan of Correction
Facility Director met with maintenance staff on site on 11/5/2012 to review fire drill requirements, to include a sleeping fire drill at least one time every six months. Maintenance staff will adhere to this standard. Facility risk committee members and facility director will ensure compliance via reviewing the fire drill log monthly during risk committee meetings. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client records.The findings include:Six client records were reviewed on October 31, 2012 and November 1, 2012. Three of the client records reviewed were discharged clients. One of the discharged clients was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 6.Client # 6 was admitted into treatment on March 29, 2012 and was involuntarily terminated from the project on August 29, 2012. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on October 31, 2012.An interview with the facility director on November 1, 2012 confirmed the findings.
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Plan of Correction
Facility Director will conduct an in-service with the counselors by 12/7/2012 to review discharge conditions in which client needs to receive, in writing, the decision to involuntarily terminate the client's treatment. . Compliance to this standard will be met via monthly closed chart monitors by the Facility Director. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in five of six client records. The findings include:Six client records were reviewed on October 31, 2012 and November 1, 2012. All records were reviewed for psychosocial evaluations.The psychosocial evaluations in client records #1 and 5 did not include an evaluation of the client's assets/strengths and how they would impact treatment. The psychosocial evaluations in client records #1 and 5 did not include an evaluation of the client's support systems and how they would relate to treatment. The psychosocial evaluations in client records #1 and 5 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment. The psychosocial evaluations in client records #1 and 5 did not include an evaluation of the client's negative factors and how they would impact treatment. The psychosocial evaluations in client records #1 and 5 did not include an evaluation of the counselor conclusions/impressions of the client. Also, per the facility policy, psychosocial evaluations are to be completed within 5 days of the client's admission date.Client #1 was admitted on August 2, 2012; the psychosocial evaluation was to be completed by August 7, 2012. At the time of the inspection the psychosocial evaluation was documented, but did not include the date when it was completed and it was not able to be determined if it was documented by August 7, 2012. Client #2 was admitted on August 21, 2012; the psychosocial evaluation was to be completed by August 26, 2012. At the time of the inspection, there was no documentation of client #2's psychosocial evaluation.Client #3 was admitted on September 11, 2012; the psychosocial evaluation was to be completed by September 16, 2012. At the time of the inspection, there was no documentation of client #3's psychosocial evaluation.Client #4 was admitted on January 26, 2012 and discharged on May 4, 2012. The psychosocial evaluation was to be completed by January 30, 2012. At the time of the inspection, there was no documentation of client #4's psychosocial evaluation.Client #5 was admitted on February 22, 2012 and discharged on May 14, 2012. The psychosocial evaluation was to be completed by February 27, 2012. At the time of the inspection the psychosocial evaluation was documented, but did not include the date when it was completed. Licensing specialist could not determine if it was documented by August 7, 2012. An interview with the facility director on November 1, 2012 confirmed the findings.
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Plan of Correction
Facility Director will conduct an in-service with the counselors by 12/7/2012 to review psychosocial evaluation documentation, to include evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment, and the counselor conclusions/impressions of the client. Facility director will also review timeline in which the evaulation is to be completed, to include ensuring the evaluation is dated when completed. Compliance to this standard will be met via monthly chart monitors of both open and closed charts by the Facility Director. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in three of six client records.The findings include:Six client records were reviewed on October 31, 2012 and November 1, 2012. Five of the six were required to show documentation of a case consultation in client records, #1, 2, 4, 5 and 6. Case consultations are to include the date, staff members present, summary of the client and the disposition. The following client's records failed to include the summary and disposition, #1 and 5. Also, per the facility's policy and procedure, case consultations are to be completed within 90 days of the client's admission date. Client #4 was admitted on January 26, 2012 and discharged on May 4, 2012. The case consultation was to be documented by April 26, 2012. As of the date of the inspection there was no documentation of client #4's case consultation. An interview with the facility director and facility staff on October 11, 2012 confirmed the findings.
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Plan of Correction
Facility Director will conduct an in-service with the counselors by 12/7/2012 to review case consult documentation, to include summary of the client (discussion piece), disposition, date, and staff members present. Facility director will also review timeline of completion of case consult. Compliance to this standard will be met via monthly chart monitors of both open and closed charts by the Facility Director. |