INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records and a discussion with the virtual learning manager and the human resources manager, the facility failed to document a written individual training plan for each employee in two of three personnel records reviewed.
The findings include:
The facility's training year runs from January to December. Individual training plans for the facility's 2011 training year were reviewed at the corporate office from May 9, 2011 through May 11, 2011. Four personnel records were reviewed. Three of those four personnel records were reviewed for individual training plans. As of May 11, 2011 an individual training plan was not documented in personnel records #3 and 4.
Staff #3 was hired on 11/4/09. A 2011 individual training plan was not documented in personnel record #3 as of 5/11/11.
Staff #4 was hired on 6/1/10. A 2011 individual training plan was not documented in personnel record #4 as of 5/11/11.
During a discussion with the virtual learning manager and the human resources manager, these findings were confirmed.
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Plan of Correction
A review of the on location records pertaining to Pottsville Program 2011 Individual training plans for calendar years 2011 was conducted on June 23 by the Division Director, and the Administrative Assistant II. It was concluded that the Individual Training Plans were completed and sent to the Training Institute. On June 28, 2011, the Administrative assistant II will fax all 2011 Individual Training Plans to The Gaudenzia Training Institute located in Norristown, PA. The fax cover sheet will state exactly what is being sent. Upon completion of fax, the confirmation sheet will be attached to the sent documents. The Administrative Assistant II will then follow up with both a phone call and an email to the virtual learning manager asking for receipt confirmation within 24 hours of being sent. If confirmation is not received within the asked time period, the Administrative Assistant II will send a second email and copy the facility Division Director. Should the information not be confirmed, the Division Director will immediately seek corrective action through the Central Region Director.
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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 records and a discussion with the virtual learning manager and the human resources manager, the facility failed to ensure that each staff person receive a minimum of 6 hours of HIV/AIDS training in one of one personnel record.
The findings include:
Four personnel records were reviewed at the corporate office from May 9, 2011 through May 11, 2011. One of those four personnel records was reviewed for HIV/AIDS training. As of May 11, 2011, there was no documentation of HIV/AIDS training in personnel record #3.
Staff #3 was hired on 11/4/09 and was a counselor. At least 6 hours of HIV/AIDS training was due on or before 11/4/10. As of 5/11/11, there was no documentation of any HIV/AIDS training in personnel record #3.
During a discussion with the virtual learning manager and the human resources manager, these findings were confirmed.
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Plan of Correction
A review of the on location records pertaining to Pottsville Program HIV/AIDS Training for Staff # 3 was conducted on June 23, 2011 by the Division Director, and the Administrative Assistant II. It was concluded that Staff #3 completed HIV/AIDS Training on April 19, 2005 and a copy of the training certificate sent to the Training Institute. On June 28, 2011, the Administrative Assistant II will fax HIV/AIDS training certificate for staff #3 to The Gaudenzia Training Institute located in Norristown, PA. The fax cover sheet will state exactly what is being sent. Upon completion of fax, the confirmation sheet will be attached to the sent documents. The Administrative Assistant II will then follow up with both a phone call and an email to the virtual learning manager asking for receipt confirmation within 24 hours of being sent. If confirmation is not received within the asked time period, the Administrative Assistant II will send a second email and copy the facility Division Director. Should the information not be confirmed, the Division Director will immediately seek corrective action through the Central Region Director.
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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 and a discussion with the virtual learning manager and the human resources manager, the facility failed to ensure that each facility director complete at least 12 clock hours of training annually in one of one personnel record.
The findings include:
The facility's training year runs from January to December. The facility's 2010 training year was reviewed for training hours. Four personnel records were reviewed. One of those four staff was a facility director and required at least 12 training hours annually.
Personnel record #2 only had documentation of 11 annual training hours for the 2010 facility training year.
During a discussion with the virtual learning manager and the human resources manager, these findings were confirmed.
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Plan of Correction
Review of the on location records pertaining to Pottsville Program Division Directors training hours for 1/11/10-12/31/10 was conducted on June 23, 2011 by the Division Director, and the Administrative Assistant II. It was concluded that the Division Director had the required number of training hours for the calendar year in question.
On June 28, 2011, the Administrative Assistant II will fax all Division Directors 2010 training hours and certificates to The Gaudenzia Training Institute located in Norristown, PA. The fax cover sheet will state exactly what is being sent. Upon completion of fax, the confirmation sheet will be attached to the sent documents. The Administrative Assistant II will then follow up with both a phone call and an email to the virtual learning manager asking for receipt confirmation within 24 hours of being sent. If confirmation is not received within the asked time period, the Administrative Assistant II will send a second email and copy the facility Division Director. Should the information not be confirmed, the Division Director will immediately seek corrective action through the Central Region Director.
A review of all staff training hours and completion is part of the weekly administrative meeting.
For the 2011 and future years, the above procedure will apply.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection and a discussion with the facility director, the facility failed to ventilate bathrooms by exhaust fan or window in one of two bathrooms.
The findings include:
A physical plant inspection was conducted on June 1, 2011 at approximately 1:30PM. It was observed and confirmed by the facility director that the facility has two bathrooms. One is a unisex bathroom for clients and the other is a bathroom for staff and is labeled "Ladies."
During the physical plant inspection, it was observed that the staff bathroom labeled "Ladies" did not have a window or an exhaust fan.
These findings were confirmed during a discussion with the facility director.
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Plan of Correction
Presently the landlord is unable to be contacted until he returns from vacation. The Divison Director will discuss the citation regarding the lack of ventilation for the bathroom with the landlord upon his return. Ventilation will be provided or the bathroom will no longer be used. There is an additional bathroom that can be used by staff, visitors and clients that does have ventilation.
The completion date for providing ventilation or vacating the bathroom will be August 31, 2011. The reason for the August completion date is due in part to not being able to contact the landlord for a two week period, and to allow the landlord time to look at the options available to provide ventilation and to have the work completed should he find it feasible.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and a discussion with the virtual learning manager, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of one personnel record.
The findings include:
Four personnel records were reviewed at the facility's corporate office on May 9, 2011 through May 11, 2011. One personnel record requiring documentation for fire extinguisher training was reviewed. As of May 11, 2011, there was no documentation of fire extinguisher training in personnel record #4. Staff #4 was hired on 6/1/10.
These findings were confirmed with the virtual learning manager.
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Plan of Correction
A review of the on location records pertaining to Pottsville Program Fire Safety/Fire Extinguisher Training and Evacuation Procedure for Staff # 4 was conducted on June 23 by the Division Director, and the Administrative Assistant II. It was concluded that Staff #4 completed Fire Safety/Fire Extinguisher Training and Evacuation Procedure June 1, 2010 as well as on January 4, 2011 with the entire staff at the Pottsville Program, and a copy of the training certificates were sent to the Training Institute. On June 28, 2011, the Administrative Assistant II will fax Fire Safety/Fire Extinguisher Training and Evacuation Procedure certificate for staff #4 to The Gaudenzia Training Institute located in Norristown, PA. The fax cover sheet will state exactly what is being sent. Upon completion of fax, the confirmation sheet will be attached to the sent documents. The Administrative Assistant II will then follow up with both a phone call and an email to the virtual learning manager asking for receipt confirmation within 24 hours of being sent. If confirmation is not received within the asked time period, the Administrative Assistant II will send a second email and copy the facility Division Director. Should the information not be confirmed, the Division Director will immediately seek corrective action through the Central Region Director. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and a discussion with the virtual learning manager, the facility failed to ensure all staff are trained to perform assigned tasks during emergencies in one of one personnel record.
The findings include:
Four personnel records were reviewed at the facility's corporate office on May 9, 2011 through May 11, 2011. One personnel record requiring documentation for emergency training was reviewed. As of May 11, 2011, there was no documentation that staff were trained to perform assigned tasks during emergencies in personnel record #4.
These findings were confirmed with the virtual training manager.
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Plan of Correction
A review of the on location records pertaining to Pottsville Program Fire Safety/Fire Extinguisher Training and Evacuation Procedure for Staff # 4 was conducted on June 23 by the Division Director, and the Administrative Assistant II. It was concluded that Staff #4 completed Fire Safety/Fire Extinguisher Training and Evacuation Procedure June 1, 2010 as well as on January 4, 2011 with the entire staff at the Pottsville Program, and a copy of the training certificates were sent to the Training Institute. On June 28, 2011, the Administrative Assistant II will fax Fire Safety/Fire Extinguisher Training and Evacuation Procedure certificate for staff #4 to The Gaudenzia Training Institute located in Norristown, PA. The fax cover sheet will state exactly what is being sent. Upon completion of fax, the confirmation sheet will be attached to the sent documents. The Administrative Assistant II will then follow up with both a phone call and an email to the virtual learning manager asking for receipt confirmation within 24 hours of being sent. If confirmation is not received within the asked time period, the Administrative Assistant II will send a second email and copy the facility Division Director. Should the information not be confirmed, the Division Director will immediately seek corrective action through the Central Region Director. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 record and a discussion with the facility director and the administrative assistant, the facility failed to maintain a written fire drill record to include whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on June 1, 2011. The fire drill record presented did not include documentation of whether the fire alarm or smoke detector was operative.
A discussion with the facility director and the administrative assistant confirmed these findings.
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Plan of Correction
Effective June 1 , 2011, the Gaudenzia CQI manager, implemented a new fire drill log which added the column to include whether the fire alarm/detector was operative or not.
Administrative staff has been directed to check the column accordingly. Should the system not be operative, the administrative staff on duty will notify immediately the Division Director, the property maintenance manager, the alarm company and all staff on duty.
The fire drill log will be reviewed monthly for accuracy at the administrative meeting. Failure to comply will result in corrective
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records and a discussion with the facility director and the administrative assistant, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records were reviewed on June 1, 2011. The fire drill log documented that a smoke detector was set off during each fire drill. During a discussion with the facility director and the administrative assistant it was noted that the facility does not set off the interconnected smoke detector because it would go off in the whole building and disrupt the other businesses. The facility has a separate smoke detector that is not interconnected. This is the smoke detector the facility director and administrative assistant informed the licensing specialist they set off during each fire drill. However, the facility does not have an exception from the Department for this alternative procedure.
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Plan of Correction
A letter was send to the Director for the Division of Drug and Alcohol Program Licensure requesting an exception. On a letter dated June 14, 2011 from the director it indicated that an exception is not needed , but approval is granted for the use of an alternate means for announcing the fire drill.Documentation that the fire system is in working order will be available for review during all licensing inspections. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of administrative materials, client records and a discussion with the facility director and the administrative assistant, the facility failed to complete follow-up in four of four client record.
The findings include:
Eight client records were reviewed on June 1, 2011. Follow-up was required in four client records. Follow-up was not documented in client records #5, 6, 7 and 8.
According to the facility's policy titled, FOLLOW UP INFORMATION: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor ' s designee, to follow-up the discharged client ' s progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
Client #5 was admitted on 11/10/10 and discharged on 4/7/11. As of 6/1/11, follow-up was not documented in the follow up log binder for client #5.
Client #6 was admitted on 11/22/10 and discharged on 4/13/11. As of 6/1/11, follow-up was not documented in the follow up log binder for client #6.
Client #7 was admitted on 10/13/10 and discharged on 3/7/11. As of 6/1/11, follow-up was not documented in the follow up log binder for client #7.
Client #8 was admitted on 11/9/10 and discharged on 2/7/11. As of 6/1/11, follow-up was not documented in the follow up log binder for client #8.
During a discussion with the facility director and the administrative assistant, these findings were confirmed.
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Plan of Correction
On June 23, 2011, a meeting between the Division Director and the Administrative Assistant II will occur to review the new follow up procedure Gaudenzia has developed. On June 24, 2011 all staff will be directed during staff meeting by the Administrative Assistant II to complete client discharge follow up within 7 days of discharge. Program Supervisor will also put out expected requirements in memo format. There will be a required second follow up that is to be done within 30 days regardless of discharge or referral status.
Both follow ups will be documented on the same form. Forms will be forwarded monthly to the Administrative Assistant II, to be reviewed for accuracy and timeliness. If compliant, they will be filed in a central follow up binder. If not meeting compliancy standards, the Division Director will follow up with staff for corrective action.
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge.
Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form].
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
.Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility ' s policy and procedure manual contained a second written policy titled: " FOLLOW UP INFORMATION. " This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
The facility's policy and procedure manual was reviewed May 9 ? 12, 2011 at Gaudenzia's Corporate Office. According to corporate guidelines, no individual facility may change any policy or form to suit facility needs. This citation regarding conflicting policies was reported to the Central Region Director and the CQI Director by the facility Division Director. The CQI Director revised the follow up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia website forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director.
An in service will be held during the all staff meeting on July 29, 2011 to implement the new policy which states; the first follow up will be completed no later than 7 days of discharge on all referred clients who have given written consent. Follow ups will be completed on all other discharged clients within 30 days regardless of discharge status.
Both follow ups will be documented on the same form.
Forms will be forwarded monthly to the Administrative Assistant II to be filed in the proper follow up log/binder. All forms will be reviewed monthly during the administrative meeting with the Division Director, and the Administrative Assistant II .Follow up will be discussed during both clinical meetings and supervisory sessions. Follow up will be completed by the Administrative Assistant I or designated staff person.
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