INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on June 11, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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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704.7(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
The facility failed to document the counselor met the educational qualifications for the position.
Employee #3 was hired as a counselor on February 12, 2020, and has a diploma in Medical Assisting, which is a non-qualifying degree for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all hired staff are qualified for the position for which they are hired as per DDAP regulations and requirements. Employee #3 was removed from the position of counselor, and a counselor with a qualified degree (Masters in Social Sciences) will be beginning work at Serenity House on 7/6/2020. Going forward, the Program Director will ensure that all future hires are qualified according to DDAP regulations per 704.7 (b)(1)(2)(3)(4)(5)(6) prior to hire. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of CPR cards and discussion with Facility Director, the facility failed to ensure that at least one person trained in CPR is onsite during the project's hours of operation. The facility failed to ensure that the 3-11pm shift had CPR coverage from April 28, 2020 until June 10, 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director and Administrative Coordinator will review training records for new hires on a monthly basis to ensure that all required trainings are scheduled and completed within the designated time frame per DDAP regulations and programmatic needs. As of 6/13/2020, all current staff have completed CPR training and are now CPR certified. The Program Director will ensure, during weekly scheduling of staff, that at least one person trained and certified in CPR and first aid is onsite at all times during the project's hours of operation. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report completed on May 26, 2020, the facility failed to ensure that the FTE counselor ratio did not exceed one FTE for every eight clients.
The Facility Ratio (FTE) is determined by dividing the total number of active D&A hours by the facility work week (40). Then, in order to obtain the overall ratio, the total number of clients is divided by the FTE.
The calculations are as follows; 10/40=.25, 10/.25=40/1 which equals to a ratio of 40:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that the client/counselor ratios are in compliance as per regulation 704.12 (a)(3)(i), and that counselors serving clients shall not exceed a maximum of 8 clients on their caseload. The Program Director will ensure through the intake process that clients are assigned to a qualified counselor whose caseload is within the maximum caseload capacity as per DDAP regulations for counselor, counselor assistant, etc. Additionally, as described above, the start of a new counselor on 7/6/2020 will ensure counselor/client ratio is in compliance. Additionally, another counselor position is available, and once filled, will further ensure compliance with the staff/client ratio. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drills for 2019-2020 and a discussion with the facility director, the facility failed to conduct unannounced fire drills at least once a month from September 2019 until March 2020.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Program Director will provide oversight of fire drill procedures to ensure compliance with licensing regulations per 705.10 (d) (1). The Program Director will ensure timely documentation of fire drills, and monitoring of ongoing progress and compliance. The Program Director will schedule fire drills, and ensure fire drills are conducted at least once per month and will be monitored through a tracking grid and reviewed monthly during Program Director meetings and monthly Safety Committee reporting. As of April, fire drills have been conducted as per DDAP regulations and are being tracking and monitored by the Program Director utilizing a tracking grid. |