INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 24 - 25, 2011 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Gaudenzia Inc. West Chester 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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704.8(a)(1) - (5) & (b) LICENSURE Qualification Level
704.8. Qualifications for the position of counselor assistant.
(1) A Master's Degree in a human service area.
(2) A Bachelor's Degree in a human service area.
(3) Licensure in this Commonwealth as a registered nurse.
(4) An Associate's Degree in a human service area.
(5) A high school diploma or General Education Development (GED) equivalent.
(b) A counselor assistant shall also complete the training requirements in 704.11 (relating to staff development program).
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure that each counselor assistant met the qualification for the position of counselor assistant.
The findings include:
On May 24, 2011 twelve personnel records were reviewed for documentation of the qualifications for the position of counselor assistant.
Three personnel records were required to have documentation of the qualifications for the position of counselor assistant.
The facility failed to provide documentation of counselor assistant qualifications in personnel record # 5.
Employee # 5 was hired as a counselor assistant on March 14, 2011.
At the time of review on May 24, 2011 the facility failed to verify a high school diploma or General Education Development (GED) equivalent for employee # 5.
The facility director stated that acceptance in a higher education program meets the projects high school diploma verification requirement.
However, the documentation that was reviewed by staff from the Division of Drug and Alcohol Program Licensure did not indicate acceptance into a higher education program rather a letter stating that the admissions application was received and detailed further requirements to gain entrance into the program.
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Plan of Correction
In reference to the citation, during the interview with Program Director, Program Director will view the original diploma/GED. It will be the Program Director's responsibility to ensure that a copy of this original document is placed in the employee's personnel file. For a counselor position, original college transcripts and/or acceptance letter from Accredited University would be obtained, viewed, copied by Program Director during that interview. As stated above, it will also be the Program Director's responsibility to ensure that a copy is placed in the personnel file.
If the prospective employee were not to have these original documents, this would inhibit the prospective individual from being hired.
In reference to employee #5's personnel file, Administrative Coordinator II assisted the identified staff to obtain a copy of the original diploma, which was then placed in the individual's personnel folder.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation and a physical plant inspection and a conversation with the program supervisor, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
A physical plant inspection was conducted on May 24, 2011 at approximately 9:30 AM.
A shower in the men ' s restroom had an uncovered drain; the drain cover was on the shower floor next to the open drain.
Bedroom # 13 had a broken window and a piece of wood was in the window frame.
The emergency exit in the basement was littered with swept up debris such as leaves and trash.
The carpet on the second floor in the dorm labeled as the "Philly Dorm" had a scorch mark in the shape of an iron. This is a repeat citation. The scorched floor was previously cited during the July 28, 2010 inspection.
The program supervisor confirmed the physical plant deficiencies.
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Plan of Correction
A work order has been submitted by the Program Supervisor on 6/1/2011. The work order has been submitted to address/fix/repair the drain in the identified men's restroom, the broken window in bedroom #13, and the carpet in the Philly Dorm, which has a scorch mark in the shape of an iron.
In regards to the emergency exit, the debris (leaves and trash) have been swept and removed.
When looking at the maintenance issues, Program Supervisor will continue to complete daily tours of the facility to identify any maintenance issues and input them into the maintenance system. All identified maintenance issues will be rectified by the 24th of June.
Finally, in order to prevent the build up of debris, Program Supervisor and Staff on Duty will check all emergency exits, including the one identified in this citation, to ensure they are clear of all debris.
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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based upon observation, a physical plant inspection and an interview with the program supervisor, the facility failed to provide a securely attached ladder for the bunk beds in room # 1 and the Philly's Room.
The findings include:
A physical plant inspection was conducted on May 24, 2011 at approximately 9:30 AM.
Bedroom # 1 had six beds, one bunk bed set was observed without a securely attached ladder.
The "Philly's Room" had 16 beds, 4 of the bunk beds were observed without a securely attached ladder.
The program supervisor confirmed the findings.
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Plan of Correction
Program Supervisor has placed an order on 6/8/11 for the ladders that were found to be missing during the inspection, which took place on 5/24/25. In addition to that, Program Supervisor will ensure that all ladders are properly installed once shipment is received, which will be completed by the 17th of June.
Finally, to ensure that all bunk beds are in compliance with Department of Health regulations, Program Supervisor and Staff on Duty will make daily tours of facility and immediately rectify missing ladders by securing them in the proper place.
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709.28(c) 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:
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Observations
Based on a review of client records, a review of clinical documents and an interview with the facility director, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in client records.
The findings include:
On May 24 - 25, 2011 seven client records were reviewed to ensure that the facility was obtaining informed and voluntary consents to release client identifying information. Documentation in client records # 4, 5, 6, and 7 failed to adhere to the requirements specified at 4 Pa. Code 255.5 (b) and 42 C.F.R. Part II, subsection 2.32.
Client # 4 was admitted to the program on 3/31/11, and at the time of review was an active client.
On 4/1/11 client # 4 signed and dated an Authorization for Release of Information form as a requirement for treatment court.
The form requested drug and alcohol treatment records, medical dental records, mental records, HIV information, and general records. A handwritten statement further stated the information being requested is: "above listed type of information."
Client # 5 was admitted to the program on 4/12/11, and at the time of review was an active client.
On 4/15/11 client # 5 signed and dated an Authorization for Release of Information form as a requirement for treatment court.
The form requested drug and alcohol treatment records, medical dental records, mental records, HIV information, and general records. A handwritten statement further stated the information being requested is: "above listed type of information."
Client # 6 was admitted to the program on 2/25/11, and at the time of review was an active client.
On 2/28/11 client # 6 signed and dated an Authorization for Release of Information form as a requirement for treatment court.
The form requested drug and alcohol treatment records, medical dental records, mental records, HIV information, and general records. A handwritten statement further stated the information being requested is: "above listed type of information."
Client # 7 was admitted to the program on 4/19/11, and at the time of review was an active client.
On 4/22/11 client # 7 signed and dated an Authorization for Release of Information form as a requirement for treatment court.
The form requested drug and alcohol treatment records, medical dental records, mental records, HIV information, and general records. A handwritten statement further stated the information being requested is: "above listed type of information."
The Authorization for Release of Information form failed to adhere to the requirements set forth at 4 Pa. Code 255.5 (b).
The Authorization for Release of Information form in client records # 4, 5, 6, and 7 were general consent to release forms. The use of which is prohibited at 42 C.F.R. Part II, subsection 2.32.
In addition, the Authorization for Release of Information form does not comply with the regulation at 42 C.F.R. Part II, subsection 2.31 or the state regulation 709.28 (c) regarding a valid consent as outlined in these laws/regulations which includes:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
Furthermore, the Authorization for Release of Information form that is required by the treatment court was not legible; as a result the Authorization for Release of Information forms in client records # 4, 5, 6, and 7 were not able to be read in entirety.
The facility director confirmed that the general consent forms are forms that the facility has clients that are in treatment court sign. She also confirmed that the forms were not legible.
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Plan of Correction
One correction to the citation is that Releases of Information had been used with all clients that have been referred to Gaudenzia House West Chester under the jurisdiction of the PA Department of Corrections.
However, in light of this citation, Program Director spoke with GHWC's Contract Facility Coordinator, who is our liaison for the Department of Corrections and our facility. Program Director shared with this individual that facility was cited for these Releases of Information being out of compliance with the state Confidentiality Laws (4 Pa. Code 255.5 (b) and 42 C.F.R. Part II subsection 2.32).
Therefore, effective June 6, 2011, the Releases of Information that were previously used for all clients referred by the Department of Corrections have been removed and prohibited from usage in our facility. This form will be reinstated once the Department of Corrections can make the necessary corrections/altercations enabling it to be in compliance with the State Confidentiality regulations listed above.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records and a review of the facility's policies and procedures, the facility failed to document physical examinations per facility policy in five of six client records.
The findings include:
The facility's policy titled "Physical Examination Laboratory Studies" states:
A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Other exceptions are:
1.The client received a complete physical examination no longer than one month prior
to admission; that the program staff can obtain the results in writing;
and the nurse on duty is able to ascertain no noticeable medical problems.
1.Any physical examination not performed by the Gaudenzia physician will be
reviewed and signed off by him/her within 24 hours of client's admission to
the residential program.
2.Pennsylvania CBH clients are to have a completed physical within 72 hours -exceptions are holiday or weekend.
Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequence of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client.
On May 25, 2011 six client records were reviewed for documentation of a physical examination.
The facility failed to document physical examinations per policy in client records # 1, 4, 5, 6, and 7.
Client # 1 was admitted to the program on 4/8/11.
The physical examination reviewed in the client chart dated and signed by the physician on 4/15/11 lacked the physician's impressions/diagnosis.
Client # 4 was admitted to the program on 3/31/11.
The physical examination reviewed in the client chart dated and signed by the physician on 4/2/11 lacked the physician's impressions/diagnosis.
Client # 5 was admitted to the program on 4/12/11.
The physical examination reviewed in the client chart was dated and signed by the physician on 4/18/11 lacked the physician's impressions/diagnosis.
Client # 6 was admitted to the program on 2/25/11.
The physical examination reviewed in the client chart was dated and signed by the physician on 3/4/11 lacked the physician's impressions/diagnosis.
Client # 7 was admitted to the program on 4/19/11.
The physical examination reviewed in the client chart was documented late on 5/2/11.
The physical examination was to complete by 4/28/11.
In addition, the physical failed to include the physician's impressions and diagnosis.
This is a repeat citation. Physical examinations were previously cited on May 19, 2009 and June 5, 2008.
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Plan of Correction
A meeting took place on the 1st of June with the Program Director and the Medical Director. During that meeting, the doctor was informed of the citation issued to the facility. Director shared with Doctor that he needed to expound on responses and impressions during the physical, especially, but not limited to, the identified areas within this citation.
To ensure that this deficiency does not occur, the Program Director and D/A Division Director have devised and implemented a continuous quality improvement measure. This measure/system includes the following:
D/A Division Director, who will be directly supervising the Medical Director until a new Regional Director is appointed, will meet with Medical Director once a month. Prior to that meeting, D/A Division Director will randomly identify a client that came into GHWC during the past month and request that the Medical Director bring a copy of the completed physical. Medical Director and D/A Division Director will review the physical to evaluate its completeness to ensure that the impressions are in compliance and completed in a quality fashion.
Finally, it will be the responsibility of the Program Director and D/A Division Director to ensure that this system is continuously implemented and follow to ultimately decrease non-compliance with policy 709.51.
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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, the standards for inpatient non-hospital activities, and an interview with the facility director, the facility failed to verify that any work done by the client is an integral part of the treatment and rehabilitation plan in four of seven client records reviewed.
The findings include:
On May 25 -25, 2011, seven client records were reviewed for documentation that any work done by the client is an integral part of the treatment and rehabilitation plan.
The facility failed to document that work done by the client was an integral part of the treatment and rehabilitation plan in the comprehensive treatment plan or treatment plan updates in client records # 1, 2, 3, and 4.
An interview with the facility director confirmed that client's participate in work outside of cleaning their personal space and that documentation has not been done.
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Plan of Correction
An in-service training was held on the 7th of June with the Clinical Supervisor and the Clinical staff to review the citation listed. Clinical Staff were trained on integrating work therapy into client's goals and have it reflected on their treatment plans (comprehensive/updated treatment plans). The Clinical Supervisor or his/her designee will review treatment plans during monthly chart audits to ensure that this integration has taken place. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge.
Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form].
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
.Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility ' s policy and procedure manual contained a second written policy titled: " FOLLOW UP INFORMATION. " This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
The Gaudenzia Policy and Procedure manual will be revised by the Director of Continuous Quality Improvement to eliminate any contradiction regarding Follow Up procedures. The policy manual will clarify that clients who have been referred by Gaudenzia to another program will be followed up on within 7 days, while clients who leave under circumstances other than referral to another program will be followed up on within 30 days. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On May 24 - 25, 2011 the facility was again found to be out of compliance with the following standard:
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
This area of noncompliance was identified during the May 19, 2009 licensing inspection.
The plan of correction was submitted on 6/5/09, and was approved on 6/10/09.
This area of noncompliance was also identified during the June 5, 2008 licensing inspection.
The plan of correction was submitted on 7/2/08, and was approved on 7/30/08.
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Plan of Correction
A meeting took place on the 1st of June with the Program Director and the Medical Director. During that meeting, the doctor was informed of the citation issued to the facility. Director shared with Doctor that he needed to expound on responses and impressions during the physical, especially, but not limited to, the identified areas within this citation.
To ensure that this deficiency does not occur, the Program Director and D/A Division Director have devised and implemented a continuous quality improvement measure. This measure/system includes the following:
D/A Division Director, who will be directly supervising the Medical Director until a new Regional Director is appointed, will meet with Medical Director once a month. Prior to that meeting, D/A Division Director will randomly identify a client that came into GHWC during the past month and request that the Medical Director bring a copy of the completed physical. Medical Director and D/A Division Director will review the physical to evaluate its completeness to ensure that the impressions are in compliance and completed in a quality fashion.
Finally, it will be the responsibility of the Program Director and D/A Division Director to ensure that this system is continuously implemented and follow to ultimately decrease non-compliance with policy 709.51. |