INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18 through May 19, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Together 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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704.7(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.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that each counselor met the qualifications for the position of counselor in one of eight personnel records reviewed during the annual licensing inspection on May 18 through May 19, 2016.
Employee # 3 was hired as a counselor on March 7, 2016 and has a non-qualifying Master Degree in Public Health and Bachelor Degree in Biology.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #3's status was changed to Counselor Assistant effective May 20, 2016.
Together House will ensure that Counselors are meet the qualifications for the position based on DDAP Policy 704.7(b) Licensure Counselor Qualifications. All new hires credentials for the counselor position will be reviewed by the Eastern Region Compliance Manager before they are hired.
Counselor Assistant will be monitored and supervised by the Program Supervisor according to DDAP Policy 704.8 (a)
The following persons will be responsible to ensure the corrective action is implemented:
Division Director
Eastern Region Compliance Director
Program Supervisor
Timeframe for Completion: May 20, 2016
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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
Based on a physical plant inspection, it was observed that the facility failed to keep the grounds of the facilty clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
Water damage to the fourth floor causing missing ceiling pieces and missing vinyl baseboard trim.
Bedroom #408- Large pieces of ceiling cut out exposing metal frames for drop-ceiling and water damage.
Bedroom #405- Missing vinyl baseboard trim where water damage occurred.
Bedroom #402-Large piece of ceiling cut out exposing metal frame for drop-ceiling.
Common Sitting Area-Large pieces of ceiling cut out exposing duct work towards the back of the room next to the second door.
These findings were reviewed with facility staff during the licesing process.
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Plan of Correction
The following repairs are scheduled to be made by the maintenance department on June 15, 2016:
Bedroom #408- Large pieces of ceiling cut out exposing metal frames for drop-ceiling and water damage.
Bedroom #405- Missing vinyl baseboard trim where water damage occurred.
Bedroom #402-Large piece of ceiling cut out exposing metal frame for drop-ceiling.
Common Sitting Area-Large pieces of ceiling cut out exposing duct work towards the back of the room next to the second door.
Per DDAP Policy 705.2(2) Building Exterior and Grounds we will keep the grounds of the facility clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of clients, staff, and visitors and all needed repairs will be reported to the Maintenance Department daily on their IT System.
To ensure this we will monitor completion of maintenance issues on our Weekly and Monthly Safety and Sanitation Reports that are completed by the House Manager of Maintenance and Operations Supervisor. These items will be reviewed during our Monthly CQI Meetings.
Division Director
Maintenance Department
House Managers of Maintenance
Operations Supervisor
Timeframe for Completion: June 15, 2016
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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent in records, #1, 2, 3, 4, 5, 6, 7, 9, and 10.
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client #1 - It was documented in the client chart that the facility released the client 's medication dosage and intimate details of their past to the funding source on March 13, 2016, April 6, 2016 and April 21, 2016 which exceeded 4 PA Code 255.5.
Client #2 - It was documented in the client chart that the facility released intimate details of the client's past to the funding source on March 18, 2016 and April 1, 2016 which exceeded 4 PA Code 255.5. In addition the facility faxed client information to a funding source on March 21, 2016 with out a consent to release form from the client.
Client #3 - It was documented in the client chart that the facility released the client 's medication to the funding source on May 2, 2016 which exceeded 4 PA Code 255.5.
Client #4- It was documented in the client chart that the facility released the client 's medication dosage to the funding source on November 20, 2015 and December 3, 2015 which exceeded 4 PA Code 255.5. In addition, a consent to release form dated October 29, 2015 to the clients funding source expired on October 29, 2015, therefore client information released on November 20, 2015 and December 3, 2015 was done with out the clients consent.
Client #5- It was documented in the client chart that the facility released the client 's medication dosage and intimate details of their past to the funding source on November 12, 2015, November 20, 2015 and November 27, 2015 which exceeded 4 PA Code 255.5.
Client #6- It was documented in the client chart that the facility released intimate details of client's past trauma to the funding source on January 5, 2016 which exceeded 4 PA Code 255.5.
Client #7- It was documented in the client chart that the facility released the client 's medication to the funding source on March 4, 2016 which exceeded 4 PA Code 255.5.
Client #9- It was documented in the client chart that the facility released the client 's medication to the funding source on March 21, 2016 which exceeded 4 PA Code 255.5.
Client #10- It was documented in the client chart that the facility released the client 's medication dosage to the funding source on November 18, 2015 and February 3, 2016 which exceeded 4 PA Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the charts #1, 2, 3, 4, 5, 6, 7, 9, and 10. We will also review all other open charts and obtain an informed and voluntary consent form for them as needed.
On June 13, 2016 a Record-Keeping training will be facilitated to review the 4 PA Code 255.5 Confidentiality Request to Release Information Form and DOH Policy 709.28 (c)(1).
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Supervisors
Together house Counselors
Timeframe for Completion: June 13, 2016
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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
The facility failed to document a complete client record on an individual, which includes information relative to the client's involvement with the project in four of twelve client records reviewed during the course of the annual licensing inspection on May 18 through May 19, 2016.
Client #5 was admitted to treatment on November 12, 2015 and discharged on December 28, 2015. The facility failed to document the client 's record of service for November 2015 and December 2015 and individual progress notes. Client was seen for group therapy on 11/17, 11/25, 11/30, 12/1, and 12/2.
Client #9 was admitted to treatment on March 11, 2016 and was still an active client at the time of inspection. The facility failed to document a consent to treatment form.
Client # 10 was admitted to treatment on November 4, 2015 and discharged on February 3, 2016. The facility failed to completely document the client's record of service for group therapy. The client was seen for individual therapy on 11/4, 11/6, 11/13, 11/20, 11/27,12/4, 12/11, 12/18, 12/25, 1/8, 1/15, 1/22, 1/29, and 2/3.
Client # 11 was admitted to treatment on January 28, 2016 and discharged on March 15, 2016. The facility failed to completely document the client's record of service for February by not documenting group sessions that took place. In addition there was no record of service for March. The record of service did document that the client was seen for individual sessions on 2/1, 2/8, 2/15, 2/22, 2/29 and group sessions on 2/1, 2/4, and 2/5.
These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
The Together House Program will document a record of service to include the date of service, type of service and the specific services provided to the individual client. In chart #9 we will complete a Consent to Treatment Form, and in charts #10 and #11 we will complete the Record of Service.
On June 13, 2016. there will be a training based on completing the Record of Service per DDAP Policy 709.53(a)(3). The training will review documenting a record of service to include the date of service, type of service and the specific services provided to the individual client.
To ensure that this does not recur, all Consent to Treatment Forms and Record of Services will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Supervisors
Together House Counselors
Timeframe for Completion: June 13, 2016
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