INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3-4, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. 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(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of 8 staff records conducted during the onsite inspection June 3-4, 2019, the facility failed to ensure that counselor assistants were supervised by a full time clinical supervisor or a counselor.
The facility ' s counselor assistants were being supervised by the facility director instead of being supervised by a full-time clinical supervisor or counselor.
Staff Person #7 was hired as a counselor assistant on November 8, 2018.
Staff person #8 was hired as a counselor assistant on May 14, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Any new hired Counselor Assistant or current counselor assistants will be supervised by the Clinical or Program Supervisor. In the absence of a Clinical or Program Supervisor, the Program Director will be responsible for delegating a counselor who meets the qualifications in 704.6 or 704.7 to provide clinical supervision to a counselor assistant. The Program Director |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the project ' s documents submitted to the Department on May 23, 2019, the project failed to follow its comprehensive staff development program for agency personnel.
The overall training plan for the project was not completed until May 16, 2019, but the projects Plan for Assessing Staff Training Needs in the project ' s policy and procedure manual reads, " The training plan shall be ready for implementation effective Jan. 31st of each year. "
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the project ' s policy and procedures manual conducted at the Department ' s headquarters from May 21-24, 2019, the facility failed to follow the project ' s comprehensive staff development program for agency personnel.
The project ' s policy and procedure manual reads, " Each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos, or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/ Clinical Supervisor.
Staff Person #2, a counselor had 7 hours of training on February 26, 2018, 5.5 hours of training on March 29, 2018, and 6 hours of training on April 30, 2018, but there were no staff training reports completed for any of these trainings.
Staff Person #3, a counselor, had 13 hours of training on January 26-27, 2019, 6 hours of training on February 20, 2018, 6 hours of training on March 1, 2018, 4 hours of training on July 18, 2018, and 4 hours of training on September 10, 2018, but there were no staff training reports completed for any of these trainings.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Program Director will be responsible for overseeing that all staff members recieving internal or external trainings complete a training evaluation form after completion of any trainings recieved. The Administrative Coordinator will be responsible for conducting monthly audits on staff training charts to ensure there is an evalutaion training form for all trainings recorded on the monthly training report. The administrator Coordintaor will be responsible for informing the Program Director of any missing evaluation forms conducted during the monthly audit.
The Program Director will be responsible for completing a table top with all staff members by August 1st to review the policy and procedures manual on submission of training evaluation forms. The Program Director will also be responsible for submitting a memo to all current staff by 8/1/19 informing them of this policy. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Base on a review of the project ' s staff records conducted on June 3-4, 2019, the project failed to ensure that all of its staff had the appropriate fire extinguisher training.
Staff Person #1, the project director, was hired on March 4, 2019, but the staff person did not receive fire extinguisher training.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Base on a review of the project ' s staff records conducted on June 3-4, 2019, the project failed to ensure that all of its staff had the appropriate emergency training.
Staff Person #1, the project director, was hired on March 4, 2019, but the staff person did not receive emergency training.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (d) (3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility ' s fire drill records from July 1, 2018, through May 31, 2019, conducted during the on-site inspection June 3-4, 2019, the facility failed to include all of the required documentation in its fire drill records.
The fire drill records for the fire drills conducted on May 30, 2019, at 12:59 AM and 1:02 AM, do not document the number of people in the building.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Program Director will be responsible for conducting a table top by 8/1/19 with all Common Ground employess on proper documentation for monthly fire drills.
The Program Director will be responsible for auditing the fire drill logs monthly to ensure all necessary information, including date and time of the evacuation, number of staff, number of clients, exits used, time of evacuation, and if the alarm was pulled, was documented properly in the log. |
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
Based on a review of client records conducted during the on-site inspection, the facility failed to obtain an informed and voluntary consent to release information for the funding source of 1 in 11 client records reviewed during the on-site inspection conducted June 3-4, 2019.
The release of information for Client #5 ' s funding source is signed by Client #5, but the form authorizes the release of information of someone other than Client #5.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
New releases were not obtained as the member was discharged on 3/11/19. Furthermore, the Program Director will be responsible for retraining all staff by 8/1/19 on proper completion of consents to release information. The intake Specialist will be responsible for auditing new intake files to ensure consents to release information are properly completed and include accurate information. These audits will occur during scheduled morning meetings. The assigned counselors will be responsible for obtaining a consent with accurate information in the event a consent to release information is found to be void or containing inaccurate information. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records conducted during the on-site inspection June 3-4, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in 11 of 11 client records reviewed.
The clients' rights forms that the clients sign at the facility do not inform the clients of the following: That the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records conducted during the on-site inspection June 3-4, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in 11 of 11 client records reviewed.
The clients' rights forms that the clients sign at the facility do not inform the clients of the following: Clients have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records conducted during the on-site inspection June 3-4, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in 11 of 11 client records reviewed.
The clients' rights forms that the clients sign at the facility do not inform the clients of the following: Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records conducted during the on-site inspection June 3-4, 2019, the facility failed to complete psychosocial assessment in 4 of 6 detoxification records reviewed.
Client #1 was admitted for detoxification on April 24, 2019, and was discharged on April 29, 2019, but there was no psychosocial evaluation completed for the client.
Client #4 was admitted for detoxification on April 16, 2019, and was discharged on April 22, 2019, but there was no psychosocial evaluation completed for the client.
Client #5 was admitted for detoxification on March 8, 2019, and was discharged on March 11, 2019, but there was no psychosocial evaluation completed for the client.
Client #6 was admitted for detoxification on April 12, 2019, and was discharged on April 16, 2019, but there was no psychosocial evaluation completed for the client.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Program Director will be responsible for conducting a training with medical staff and detox counselors on timelines for completion of biopsychosocial evaluations.
The RN supervisor will be responsible for ensuring Biopsychosocial evaluations are completed within 3 days of admission by completing a tracking sheet for all information entered into the EHR system.
The RN supervisor will be responsible for delegating nursing staff to complete the Biopsychosocial evaluations during the weekend when the detox counselors are not present.
This plan of corrected will be completed by 8/15/19 |
715.14(d) LICENSURE Urine testing
(d) A narcotic treatment program shall ensure that a laboratory that performs the testing required under this section shall be in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U.S.C.A. §§ 201 note, 263 and 263a notes), and State requirements, specifically the Pennsylvania Clinical Laboratory Act (35 P.S. §§ 2151-2165) and Chapter 5 (relating to clinical laboratories).
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Observations
Based on a review of facility documents conducted during the on-site inspection June 3-4, 2019, and at the Department ' s headquarters on June 19, 2019, the facility failed to ensure that the laboratory that it used for its urine screen was in compliance with applicable state and federal requirements.
The facility did not provide documentation upon request that the laboratory that performs the testing required under this section was in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U. S. C. A. note, 263 and 263a notes).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director contacted the Department of Health on 6/25/2019 to obtain the necessary applications from the Department of Health to obtain a CLIA waiver for the facility.
The Program Director will be responsible for completing and submitting the application to the Department of Health by 8/1/2019 to be in compliance with Federal requirements.
The facility will refer all new admits to a local osteopathic hospital with a valid CLIA certificate and waiver to conduct all urinalysis and blood testing upon admission and during the course of treatment until a valid CLIA waiver is obtrained.
The Program Director will be responsible for completing the annual renewal application to the Depatment of Health to ensure the CLIA waiver is renewed annually and the facility remains in compliance |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of the project's policy and procedure manual, the project ' s grievance procedure does not address permitting patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director.
Based on a review of the project's policy and procedure manual, the project's grievance procedure does not address grievances filed by patients against the narcotic treatment program director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Grievance Procedure to accurately reflect the DDAP 715.22 regulations regarding a client's right to file a grievance. The document now indicates that, clients are ensured a full and fair opportunity to be heard, to question and confront persons and evidence used against them, and to have a fair review of their grievances by the narcotic treatment program director. Grievances filed by clients against the narcotic treatment program director will be heard by the Division Director, Regional or Deputy Regional Director, and/or the Corporate Compliance Officer. This revised Policy will be distributed to all programs by 8/9/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/30/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the orientation manual is being completed. |