INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24 - 26, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia People With Hope/Short-Term Program was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to ensure that each counselor complete at least 25 clock hours of training annually.
Counselors #1 and 2 completed 18 hours of annual training.
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Plan of Correction
Counselor 1 and 2 will have completed all of the required trainings by the end of this calender year. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The facility failed to ventilate each bathroom.
The ventilation systems were inoperable in the second-floor bathrooms, staff bathroom, men's bathroom, and women's bathroom.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
The new exhaust fans have been ordered, however to date they have not been received.
The maintenance department will assure installation by September 28, 2018.
Dr. Monaco will be responsible for making sure the bathroom fans are installed. |
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
The facility failed to maintain each bathroom in a clean and sanitary manner.
There was a ceiling leak in the men's bathroom on the second floor.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
The leak in the men's bathroom was repaired.
Dr. Monaco will be in communication with the maintenance department to ensure that the corrective actions are implemented.
Steps taking will be weekly safety reports to the safety committee and the maintenance department |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document type and frequency of treatment and rehabilitation services on each treatment plan.
Treatment plans in client records # 3, 4, 5, and 8 did not include type and frequency of treatment and rehabilitation services.
Client #3 was admitted on April 30, 2018
Client #4 was admitted on May 11, 2018
Client #5 was admitted on July 13, 2018
Client #8 was admitted on July 6, 2018
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
The identified areas of concern were communicated to the designer of the electronic health record system and will be rectified by end this year, however currently all clinical staff have been directed to enter type and frequency in the comment section.
There will be paper records of service until the electronic health records form is created.
The program director will ensure that each clinician documents every record of service for each of their caseloads. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
The facility failed to document a complete record in five out of eight client records.
Client records # 2, 3, 6, 7, and 8 did not include a record of services provided.
Client #2 was admitted on September 22,2017 and discharged on January 11, 2018
Client #3 was admitted on April 30, 2018
Client #6 was admitted on July 10, 2018
Client #7 was admitted on June 25, 2018
Client #8 was admitted on July 6, 2018
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia is in the process of implementing electronic health records. The identified missing record of service will be hand written at this time until this document is fully implemented in the new electronic system.
The program director will be responsible for ensuring that the records of service is completed by each clinicians caseload
The record of service will be a paper document until we can create the document in our electronic health records. |