INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia 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:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to provide documentation of at least two years of supervision experience and completion of a core curriculum in clinical supervision for employee # 3.
Employee # 3 was hired on October 29, 2018 and was still employed as a Clinical Supervisor at the time of the inspection.
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Plan of Correction
Employee #3 is no longer employed at Gaudenzia House West Chester as of January 9, 2019. The agency has determined that it was not a good fit. Moving forward the hiring committee will make sure that the next Program Supervisor that is considered for the position, has at least 2 years of Clinical Supervision experience prior to being offered the position. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
The facility failed to provide documentation of a semi-annual review for employee #'s 10 and 11.
Employee # 10 was hired as a counselor assistant on April 16, 2018 and was still in the position on the date of the inspection. There was no documentation of a semi-annual review that was due October 16, 2018
Employee # 11 was hired as a counselor assistant on June 11, 2018 and was still in the position on the date of the inspection. There was no documentation of a semi-annual review that was due December 11, 2018
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Plan of Correction
Director will review all semi annual reviews to assure that hey have been completed in a timely manner. The Director will has implemented a Manager weekly meeting where she will meet with all Managers to discuss all documentation. An HR grid has been generated that identifies staff hire dates, training dates, semi-annual reviews due and annual review due, among other other pertinent information needed. |
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
The facility failed to provide supervision for at least the first six months of employment for employee # 10 and 11.
Employee # 10 was hired as a counselor assistant on April 16, 2018 and was still in the position on the date of the inspection. There was no documentation of supervision in the employee record.
Employee # 11 was hired as a counselor assistant on June 11, 2018 and was still in the position on the date of the inspection. There was no documentation of supervision in the employee record.
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Plan of Correction
The Director will implement a Manager weekly meeting where she will meet with all Managers to discuss all documentation. An HR grid has been generated that identifies staff hire dates, training dates, semi-annual reviews due, supervisions due dates especially for new hires, and annual review due, among other pertinent information needed. |
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
The facility failed to provide 12 clock hours of training for employee # 1.
Employee # 1 was hired for current position in 1988. There was no documentation of 12 clock hours of annual training in the employee record.
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Plan of Correction
Director has made arrangements to have a copy of employee #1 training information onsite at the program all year round. This will ensure that training information for this employee is available when needed during audits/inspections. |
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
During an on-site physical plant inspection, a bathroom located on the basement floor was observed to be in disrepair including a clogged toilet and odor. The male bathroom/shower area was observed to have mold in the showers, floors and walls in disrepair, and toilet stalls that did not have adequate toilet paper holders.
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Plan of Correction
Maintenance department immediately took care of the clogged toilet in the bathroom located on the on the basement. Director also made sure that new toilet paper holders were installed in all bathroom room stalls in the facility. Maintenance department along with outside cleaning company took care of what appeared to be mold in all shower areas in the facility. Initial clean-up began on 12/23/2018. A follow-up is scheduled for January 30, 2019. Director has included weekly GI of the facility on Saturday. During this time all members in the facility are giving specific chores that they need to make sure are done. In addition, facility staff will check all chores during GI ti make sure that they have been completed. Facility staff also need to sign the report confirming the chore has been done and that they have observed it. This will make sure that there is no debris build up throughout the facility including the bathrooms. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
During an on-site physical inspection conducted on December 17, 2018, the facility failed to store food items off the floor. Boxes of chips were observed on the small pantry floor.
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Plan of Correction
Director has generated a checklist that has been posted in small pantry area. The checklist serves as an accountability tool to make sure that no snacks are left on the floor. The Kitchen Supervisor or Designee will be required to complete the checklist on a daily basis to make sure that no snack boxes are on the floor. The Kitchen Supervisor or Designee must sign the checklist confirming that they have observed all snack boxes off the floor. A copy of the completed checklist will be given to the Director and the original will be placed in a binder in the Kitchen Supervisor's office. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
During a facility plant inspection on December 17, 2018, the facility failed to provide adequate lighting in the interior fire exit stairwell from the second floor.
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Plan of Correction
Maintenance department installed proper lighting in the interior fire exit stairwell from the second floor. This interior fire exit has been included in the maintenance report to be checked weekly during the walk through the facility. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
In client record # 7, the facility failed to ensure that there was appropriate written documentation that the client acknowledged he/she had been made aware of their rights.
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Plan of Correction
Director or assignee are responsible to review all new admission documentation within the first 7 days of the member's admission to assure that all intake, clinical and medical information is present and has been completed in a timely manner. This will include the member acknowledging their client rights within the intake process. This new process will capture any missing documentation in the electronic health
records within the first 7 days of the member being admitted in the program. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to report 2 unusual incidents requiring the presence of police, fire, or ambulance to the department within 3 business days.
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Plan of Correction
Director has implemented new process where all incident report are to be scan/email to Director as soon they have been completed. Director will in turn complete County and State reports and assure that they are forwarded. In addition, the unusual incident binder is reviewed on a weekly basis by Administrative staff to make sure that all incident reports are present and have been sent to all parties. |
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 provide a complete client record, which is to include verification of work being done by the client at the project is an integral part of the treatment and rehabilitation plan and follow-up information in client records # 1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on October 3, 2018 and was still an active client at the time of the inspection. Work being done at the facility was not part of the client ' s comprehensive treatment plan.
Client #2 was admitted on October 30, 2018 and was still an active client at the time of the inspection. Work being done at the facility was not part of the client ' s comprehensive treatment plan.
Client #3 was admitted on November 13, 2018 and was still an active client at the time of the inspection. Work being done at the facility was not part of the client ' s comprehensive treatment plan.
Client #4 was admitted on November 21, 2018 and was still an active client at the time of the inspection. Work being done at the facility was not part of the client ' s comprehensive treatment plan.
Client #5 was admitted on October 23, 2018 and was still an active client at the time of the inspection. Work being done at the facility was not part of the client ' s comprehensive treatment plan.
Client # 6 was admitted on November 14, 2018 and discharged on December 6, 2018. Work done at the facility was not part of the client ' s comprehensive treatment plan. There was no follow-up information in the client record.
Client # 7 was admitted on June 30, 2018 and discharged on August 3, 2018. Work done at the facility was not part of the client ' s comprehensive treatment plan.
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Plan of Correction
Director or Designee will randomly review all electronic health records to make sure that all clinical documentation is completed in a timely manner. This will assure that treatment plans are capturing the work that the member is engaging in the community. All Counselors will be registered to attend a 2 day Clinical Documentation training. This will make sure that the Counselors understand the purpose of each clinical form and how to highlight in the clinical documentation the member's work. Program Supervisor/Clinical Supervisor will review Counselor's caseload during supervision to make sure that the clinical documentation is completed accurately and provide the Counselor support as needed. |