INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 2019, by staff from the Division of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Gaudenzia Inc. Harrisburg Concept 90 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(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 #4, a counselor, had 6 hours of training on March 22, 2018, and 13 hours of training on January 30-31, 2018, but there were no staff training reports completed for any of these trainings.
Staff Person #7, a counselor assistant, had 6 hours of training on September 11, 2018, and 6 hours of training on February 2, 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 review all monthly training reports to ensure staff members properly complete and forward training feedback forms with their training certificates for all trainings attended.
On 6/18/19, staff member #7 completed training feedback sheets for trainings attended on 9/11/18 and 2/2/18. For staff member # 4, training feedback sheets could not be completed as that staff member is no longer employed at the facility. |
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
Based on the physical plant inspection conducted on June 17, 2019, the facility failed to ensure that it kept bathrooms functional at all times.
At the time of the physical plant inspection the faucet handles for two of the three showers in the men's shower room were broken.
These findings were reviewed with facility staff as part of the licensing process.
This is a repeat citation from the June 4, 2018 annual inspection.
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Plan of Correction
The Program Director/Program Supervisor discussed the results of the inspection with staff members to ensure all staff members follow proper reporting protocols for all maintenance issues. In addition, the Program Director/Program Supervisor will conduct weekly facility inspections of the physical plant, as well as quarterly inspections by the Regional Physical Plant Manager. All identified maintenance issues that cannot be immediately repaired will be submitted through Gaudenzia's Maintenance reporting system.
On 6/25/19, replacement faucet handles were installed to correct the cited broken handles. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection conducted on June 17, 2019, the facility failed to keep frozen foods at or below 0 degrees Fahrenheit.
At the time of the physical plant inspection the kitchen freezer had a temperature of 5 degrees Fahrenheit.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Program Director is responsible to oversee food service operations and maintain proper functioning equipment. The Program Director will conduct weekly inspections of the food service operations and equipment, in conjunction with the cook, to ensure all activities/equipment are adhering to applicable regulations. Internal thermometers are utilized in addition to the external digital temperature gauges on all refrigerators and freezers. One freezer did not have the internal thermometer, and the external digital temperature gauge was reading incorrectly. On 6/18/19, an internal thermometer was placed in the freezer, which subsequently read -15 degrees Fahrenheit. Additionally, on 6/18/19, a work order was submitted to address the digital external thermometers. |
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
Based 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
Based 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. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the project 's policy and procedure manual conducted at the Department 's headquarters from May 21-24, 2019, the facility failed to complete its admission and treatment documentation within the time frames adopted by its governing body.
The project 's policy and procedure manual reads that the biopsychosocial history and assessment must be completed within 5 days of admission for all residential programs.
The facility is a long term residential treatment program, and the project ' s policy and procedure manual reads that individual treatment plans are to be completed 30 days from the date of preliminary treatment plan for long term residential programs.
Client #1 was admitted for residential treatment on March 26, 2019, and was an active client at the time of the on-site inspection, but there was no biopsychosocial assessment for the client at the time of the inspection.
Client #2 was admitted for residential treatment on May 6, 2019, but the client ' s biopsychosocial assessment was not completed until May 15, 2019.
Client #5 was admitted for residential treatment on January 16, 2019, but the client ' s biopsychosocial assessment was not completed until January 24, 2019.
Client #5 was admitted for residential treatment on January 16, 2019, and was discharged on March 22, 2019. The client ' s preliminary treatment plan was completed on January 16, 2019, but there was no individualized treatment plan completed for the client.
Client #6 was admitted for residential treatment on November 15, 2018, and was discharged on February 7, 2019. The client ' s preliminary treatment plan was completed on November 19, 2018, but the individualized treatment plan was not completed until January 5, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Program Director reviewed the policies under 709.24 with the Clinical Supervisor, and the policies were reviewed with the clinical team on 6/20/19 and 6/27/19. The Clinical Supervisor will review all charts weekly for compliance to ensure documentation is completed per regulations. The Program Director will monitor compliance through monthly CQI.
The biopsychosocial was completed for client #1 on 6/19/19. No correction could be made for client #2 as the biopsychosocial was completed, but cited for lateness. For clients #5 and #6, no corrections could be made as the clients were no longer in treatment. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records conducted during the on-site inspection June 17, 2019, the facility failed to ensure that treatment plans were updated at least once every 30 days in two of four applicable client records.
A total of seven client records were reviewed during the on-site inspection, and four of the seven records required treatment plan updates.
Client #3 ' s individualized treatment plan was completed on April 25, 2019, but the treatment plan was not updated until June 13, 2019.
Client #7 ' s individualized treatment plan was completed on January 7, 2019, but the treatment plan was not updated until February 20, 2019.
These findings were reviewed with facility staff as part of the licensing process.
This is a repeat citation from the June 4, 2018 and the June 27, 2017 annual inspections.
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Plan of Correction
The Program Director reviewed the policies under 709.52 with the Clinical Supervisor, and the policies were reviewed with the clinical team on 6/20/19 and 6/27/19. The Clinical Supervisor will review all charts weekly for compliance to ensure documentation is completed per regulations. The Clinical Supervisor will hold weekly clinical team meetings to review compliance and to remind clinicians of upcoming due dates for treatment plan updates. The Program Director will monitor compliance through monthly CQI.
The treatment plan for client #3 could not be corrected as it was completed late. The treatment plan for client #7 could not be corrected as the client was no longer in treatment. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records conducted during the on-site inspection June 17, 2019, the facility failed to ensure that the counseling the clients received matched the clients ' individualized treatment plans in three of seven client records reviewed during the on-site inspection.
Client #3 ' s individualized treatment dated April 25, 2019, documents the client is to receive individual counseling weekly, but there was no documented individual counseling from May 4, 2019, through June 12, 2019.
Client #6 ' s individualized treatment dated November 19, 2018, documents the client is to receive individual counseling and group counseling weekly, but there was no documented counseling from November 20, 2018, through the client ' s discharge on February 7, 2019.
Client #7 ' s individualized treatment dated January 7, 2019, documents the client is to receive individual counseling weekly, but there was no documented counseling from January 8, 2019, through the client ' s discharge on February 27, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Program Director reviewed the policies under 709.52 with the Clinical Supervisor, and the policies were reviewed with the clinical team on 6/20/19 and 6/27/19. The Clinical Supervisor will review all charts weekly for compliance to ensure documentation of weekly individual counseling is completed per regulations. The Clinical Supervisor will hold weekly clinical team meetings to review compliance. The Program Director will monitor compliance through monthly CQI.
The client charts were unable to be brought into compliance as the clinician did not take notes for individual sessions conducted with client #3, and clients #6 and #7 are no longer in treatment. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records conducted during the on-site inspection June 17, 2019, the facility failed to ensure that it documented discharged summaries in one of three applicable client records.
A total of seven client records were reviewed during the on-site inspection, and three of the seven records required discharge summaries.
Client #5 was admitted for treatment on January 16, 2019, and discharged on March 22, 2019, but there was no discharge summary 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 reviewed the policies under 709.53 with the Clinical Supervisor, and the policies were reviewed with the clinical team on 6/20/19 and 6/27/19. The Clinical Supervisor will review all charts weekly for compliance to include discharged clients to ensure the discharge summary is completed per regulations. The Clinical Supervisor will hold weekly clinical team meetings to review compliance. The Program Director will monitor compliance through monthly CQI.
The discharge summary for client #5 could not be completed as the clinician assigned is no longer employed at the facility. |