INITIAL COMMENTS
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This report is a result of an on-site inspection for licensure renewal and for the approval to use a narcotic agent, specifically Buprenorphine, in the treatment of narcotic addiction. The inspection was conducted on May 9-10, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of employee personnel records, the facility failed to document the required period of close supervision in one of one counselor assistant records reviewed.
Eight personnel records were reviewed on May 9-10, 2016. One of the eight personnel records reviewed was for the position of a counselor assistant. This employee required 3 months of direct observation and 9 months of close supervision, based on their high school diploma or GED.
Employee # 7 was formally promoted to the counselor assistant position on 4/19/15. The employee's close supervision started on 4/20/15 and was to end on 4/19/16. Supervision notes for the time period of 6/25/15 - 9/20/15 were not documented for review during the licensing inspection.
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Plan of Correction
As it appears that there are 12 Supervision notes lacking for the counselor assistant in question, and, as it would not be ethical to attempt to write them for the period during which they were overlooked, Program Supervisor and/or Director will provide a total of twelve supervisory notes, beginning at what would have been the end of the close supervision period, to compensate for the period during which the notes are missing. The notes in question will appear in the personnel file of the counselor assistant in question not later than June 30, 2016. The Program Director will be responsible for insuring this, and will insure, via monthly review og counselor assistant personnel files, that supervision notes are being done/completed on an on-going basis. Program Director will be responsible for insuring this process, and that all supervision notes are kept current. |
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.
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Observations
A physical plant inspection was conducted on May 10, 2016.
The findings include:
1) A broken window pane was observed in bedroom # 8. Jagged glass had not been removed from the window pane and it was not covered.
2) A hole in the wall was observed in bedroom # 8.
3) The blinds covering the bathroom window in bedroom # 8 were damaged and missing slats.
4) A trash can located in the kitchen food preparation area was not covered with a lid.
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Plan of Correction
1) The broken window sited here has been repaired.
2) The hole in the wall that was observed in room 8 has been repaired.
3) Replacement blinds for the bathroom window in room 8 are on order.
4) The cook has been advised that under no circumstances is the trash can lid to be off the trash can, except when the can is actually being used to receive trash; she is instructed to train each new kitchen crew as to this requirement.
Program Director was responsible for seeing to the repairs already made, and is responsible for seeing that those not complete, are completed. ALL will be done not later than 6/30/16. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
A physical plant inspection was conducted on May 10, 2016. Exhaust fans in resident bathrooms throughout the facility were observed to have a build up of dust and lint that had not been cleaned. This is a repeat citation, as the facility was cited for non-compliance of this standard as the result of a physical plant inspection conducted on September 14, 2015.
Additionally, an exhaust fan cover was observed to be partially hanging from the ceiling in the bathroom for bedroom # 8.
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Plan of Correction
An attachment is on order for the shop vac at Common ground which will permit us to reach dust that is inside the mechanisms of the exhaust fans; on its arrival, we will remove the build up of dust that has occurred there. The fan cover in room 8 has been re-fastened to the ceiling. The Program Director is responsible for seeing that the cleaning of the remaining fans is completed by 6/30/16. Program Director will be responsible for weekly inspections of the fans to insure that they are kept free of dust or the build-up of any sort of dirt either on their covers, or on the mechanism in question. |
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
A physical plant inspection was conducted on May 10, 2016, between 2:00-3:00 pm. The inspection of the food storage areas found that one freezer showed a temperature higher than 0 degrees Fahrenheit. This freezer, located in the kitchen management office, showed the temperature to be at 10 degrees. A review of the freezer log showed that this freezer was above 0 degrees daily on May 3-7, 2016.
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Plan of Correction
As this issue was noted for the nigh- shift temperature log only, the director investigated and found that the night shift house manager was neglecting to note the (-) minus sign that appears on the thermometer for the freezer in question; the cook, therefore, has trained the house manager so that she will note the (-) minus sign in her reading of the temperature of the freezer in question, going forward. The director takes responsibility for seeing that this is done, and that the readings are done correctly, retroactive to May 10, 2016. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, the facility failed to ensure that hard copy client records were secured within locked storage containers.
A physical plant inspection was conducted on May 10, 2016, during the renewal inspection. Hard copy client records were observed to be stored in four filing cabinets, which were located in an open area within the 3rd floor administrative office. It was observed that a key was left in the lock of one of the four filing cabinets. It was also observed that the other three filing cabinets were unlocked. The facility confirmed that these three filing cabinets remain unlocked and the whereabouts of a designated key was unknown. The facility also confirmed that the door in the entrance to the administrative office is not locked at all times.
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Plan of Correction
The keys to the filing cabinets in question have been located; the cabinets will be kept locked at all times, going forward, except when specifically in use. The door that is unlocked is at the foot of the third floor stairs; the administrative office, itself, is locked when unoccupied by administrative staff. Director takes responsibility for seeing that the file cabinets are locked, and remain locked unless staff are specifically using them to file, or locate closed charts. |
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.
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Observations
Fourteen client records were reviewed on May 9-10, 2016. The facility failed to obtain an informed and voluntary consent where consent was applicable in client record # 7.
Client # 7 was admitted into detox treatment on 1/28/16 and was discharged on 2/1/16. The client's record indicated that documents were faxed to the client's employer on 1/29/16, indicating the client's presence in treatment. A consent to release information to the client's employer was not documented in the client's record.
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Plan of Correction
This was a clear breach of confidentiality, however unintentional it may have been; a supervisory session has been completed on the staff person who failed to have a release signed, and the program director addressed the issue of releases in the all staff meeting at the end of May, to insure that no such breach occurs again. Program Director will monitor to insure that confidentiality is strictly maintained. |
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
Seven client records for inpatient treatment were reviewed on May 10. 2016. Based on the review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan or treatment plan update in client records # 8, 13, and 14.
Client # 8 was admitted into treatment on 4/10/16 and was still active at the time of the inspection. A treatment plan update completed for the client on 4/29/16 indicated that the client was to receive individual counseling sessions once a week. The client received individual counseling sessions on 4/14/16 and 4/15/16.
Client # 13 was admitted into treatment on 9/4/15 and was discharged on 10/8/15. The individual treatment and rehabilitation plan completed for the client on 9/10/15 indicated that the client was to receive individual counseling sessions once a week. The client received individual counseling session on 9/9/15, 9/23/15, and 9/29/15. The client did not receive an individual counseling session the week of 9/13/15 - 9/19/15.
Client # 14 was admitted into treatment on 10/13/15 and was discharged on 11/9/15. The individual treatment and rehabilitation plan completed for the client on 10/28/15 indicated that the client was to receive individual counseling sessions once a week. The client received individual counseling sessions on 10/14/15, 10/29/15, and 11/3/15. The client did not receive an individual counseling session the week of 10/18/15 - 10/24/15.
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Plan of Correction
1) Director has engaged in supervisory session with clinician associated with client #8; he will conduct individual sessions as indicated in treatment plans, and document them at the time they occur, so that client charts will reflect their timeliness.
2) Director engaged in supervisory session with personal counselor of client #13; therapist will conduct individual sessions as indicated in treatment plan and document them at the time they occur, so that charts will reflect their timeliness.
3) Director engaged in supervisory session with personal counselor of client #14; therapist will conduct individual sessions as indicated in treatment plans, and will document them at the time they occur, so that charts will reflect their timeliness.
Director will be responsible for insuring, through program supervisor, that this occurs.
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Seven client records for inpatient treatment were reviewed on May 10, 2016. The facility failed to ensure that a complete record was documented in client records # 8, 9, 12, and 13.
Client # 8 was admitted into treatment on 4/10/16 and was still active at the time of the inspection. A progress note in the client's record indicated that the client attended an individual counseling session on 4/15/16. This counseling session was not documented on the client's record of service.
Client # 9 was admitted into treatment on 4/27/16 and was still active at the time of the inspection. A progress note in the client's record indicated that the client attended a group counseling session on 4/29/16. This counseling session was not documented on the client's record of service.
Client # 12 was admitted into treatment on 8/18/15 and was discharged on 9/15/15. Progress notes in the client's record indicated that the client attended individual counseling sessions on the following dates: 8/25/15, 8/31/15, 9/7/15, and 9/13/15. These counseling sessions were not documented on a record of service for the client. Additionally, progress notes in the client's record indicated that the client attended group counseling sessions on the following dates: 8/20/15, 9/1/15, 9/2/15, 9/4/15, 9/9/15, and 9/14/15. These counseling sessions were also not documented on a record of service.
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Plan of Correction
In the June, 2016 all staff meeting, Director will address the issue reflected in this observation: that neither individual, nor group counseling sessions have been consistently documented in the record of service provided for that purpose in each chart. The Program Director, through the Program Supervisor, will be responsible for insuring that this documentation of sessions occurs immediately upon completion of those sessions, to insure currency of charts, effective immediately upon closing of that staff meeting. |