INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia New Destiny 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 and a plan of correction is due on September 17, 2007.
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Plan of Correction
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709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
The facility failed to include activities and accomplishments of the preceding year for the facility in the 2005-2006 annual report.
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Plan of Correction
The annual report FY 07 will be printed and available to the public for the current fiscal year and every year after and will include activities and accomplishments for the previous FY. The person responsible will be the Director of Development. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project failed to include time frames and available resources for the 2007-2008 project goals and objectives.
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Plan of Correction
Action steps and timelines will be written during September for the FY 07 as well as revised goals and objectives for FY 08 along with corresponding action steps and timelines. Executive staff who are responsible for specific goal areas will develop and revise plans in specific goal areas in consultation with their respective Board of Committees fand available resources for approval at the September Board Meeting and every September thereafter. Persons responsible - Execute Staff. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to adhere to confidentiality restrictions. The specific information disclosed to the funding source and to the criminal justice system exceeded 4 Pa. Code, Subsection 255.5(b) in that the consent to release information form documented that the specific information to be released included the initial evaluation and treatment goals in five of six client records reviewed, #2, 3, 4, 5 and 6.
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Plan of Correction
Consent to release information forms have been changed as not to exceed 4 Pa. Code, subsection 255.5(b). Program Director will review with clinical adn administrative staff confidentiality restrictions, and specific information to be disclosed to funding sources and criminal justice systems. Program Director will have a monthly file review for appropriate content to release information. Forms to be reviewed for the QI meeting. |
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
The facility failed to ensure that cold food was kept at or below 40 degrees Fahrenheit and frozen food was kept at or below 0 degrees Fahrenheit. There were no thermometers in the refrigerator or freezer to ensure the appropriate temperature.
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Plan of Correction
It will be insured that refrigerators will be kept at 40 degrees Fahrenheit and freezers will be kept at or below 0 degrees Fahrenheit. Thermometers have been purchased and have been placed in all units to ensure this standard is met. A tracking sheet has been developed and implemented and will be completed twice daily by House Managers and serviced weekly by Program Director or as needed if there are any problems. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility to document a complete psychosocial evaluation. A composite picture of the client was missing in four of four client records reviewed, #1, 2, 3 and 4. The client's preferred coping mechanisms were missing in three of four client records reviewed, #2, 3 and 4.
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Plan of Correction
The psychosocial evaluation will provide a composite picture of the client to include the client's preferred coping mechanisms. The Program Director will provide training to the clinical staff to detail how this is to be addressed and documented in the client file. Program Director will review psychosocials for the QI meeting monthly and weekly for clinical meeting to ensure compliance. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records and documentation submitted to the Department for review, the facility failed to hire a facility director who met the qualifications for this position. On February 20, 2007, the Department reviewed the qualifications for employee #2's and sent notice to the facility that this person did not meet the qualifications for the position of facility director. The facility hired employee #2 for this position despite the notice.
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Plan of Correction
Division Director will assume responsibiities as facility director effective immediately. Division Director will remain serving in this capacity until an appropriate candidate is approved. |
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 staff schedules and training documentation, the facility failed to ensure that at least one person trained in CPR and first aid was onsite during the project's hours of operation for twenty-five of twenty-eight days between July 1, 2007 though July 28, 2007. CPR certification had expired for six of ten employees.
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Plan of Correction
New Destiny will ensure tha during all hours of operation at least one staff person on duty will be certified in CPR and First Aid trained in order to be in compliance with regulations. The Program Director completes the staff work schedule and thus will ensure that CPR and First Aid trained staff is on the schedule 24 hours per day, 7 days per week. The Program Director will also unsure that all new staff receives CPR and First Aid training in the first 30 days of employment. The Program Director will further ensure that the staff receives updated training in these areas when necessary in order to maintain compliance. |