INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26-27, 2017, by staff from the Division of Drug and Alcohol Program Licensure. 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(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 facility records submitted during the presubmission process, and staff interviews conducted during the onsite inspection, the facility failed to ensure that all of the staff received the required training in communicable diseases.
Staff Person #8 was hired as a counselor assistant on 01/26/2015, but at the time of the onsite inspection, the staff person still had not received 4 hours of training in TB/STD's.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility will ensure that all staff receive the required training as per regulations within established timeframes including training in communicable diseases.
The individual lacking training in TB/STDs has been registered for said training by the Program Supervisor. Training is scheduled for 7/19/17.
Ongoing compliance with staffing regulations and training will be monitored monthly by the Program Director and Program Supervisor via review of a monthly training report and tracking forms.
Projected date of completion: 7/19/17
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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 facility records conducted during the onsite inspection, and staff interviews conducted during the onsite inspection, the facility failed to document treatment plan updates at least every 30 days in 2 of 5 records reviewed.
Client #2 was admitted for treatment 12/28/2016, and discharged on 03/28/217. The client's individualized treatment plan was dated 01/02/2017, and was updated on 02/01/2017, and 03/03/2017. The client's treatment plan update dated 03/03/2017, was missing the pages documenting the goals and steps of the treatment plan, and the update did not document the client's progress since the 02/01/2017, update.
Client #4 was admitted for treatment on 11/08/2016, and discharged on 02/06/2017. The client's individualized treatment plan was completed on 11/13/2016. The client's treatment plan update was due 12/13/2017, but there was no documented treatment plan update for the client.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility will assure that treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
The Program Supervisor has reviewed established timeframes and components for completing treatment plan updates as per regulations and organizational policy with clinical staff.
The Program Director and Program Supervisor will monitor ongoing compliance and provide staff feedback during clinical case meetings and monthly chart audits. Findings will also be reported via the Continuous Quality Improvement system.
Projected target resolution date: 7/13/17 |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records conducted during the onsite inspection, and staff interviews conducted during the onsite inspection, the facility failed to document verification that the work the clients did at the facility was part of their treatment and rehabilitation in 7 of 7 records reviewed.
The clients of the facility are assigned to help with meal preparation and the cleaning of common areas of the facility, but clients #1, 2, 3, 4, 5, 6 and 7, had nothing in their treatment plans verifying that work done at the facility was an integral part of the rehabilitation and treatment plan.
The findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The program will ensure that a complete client record is maintained on each individual, including information relevant to the client's involvement with the project and specifically verification that work done by the client at the project is an integral part of his/her treatment and rehabilitation plan.
The Program Supervisor reviewed relevant established regulations and organizational policy with Clinical Staff. Staff will document client work assignments on the treatment plan and a job diary.
The Program Director and Program Supervisor will monitor ongoing compliance via monthly chart audits and the Continuous Quality Improvement process.
Projected Date of Completion: 7/13/17
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