INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 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., Vantage House 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of staff records conducted during the on-site inspection June 25, 2019, the facility failed to document the required supervision for its counselor assistants.
Staff Person #7 was hired as a high school diploma level counselor assistant on August 22, 2018. The staff person was required to have documented close supervision weekly for the months of April, May and June for the year 2019, but there was only monthly documented supervision for April and May, and there was no documented supervision for June.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Effective 7/8/19, the counselor assistant (Staff person #7) has resigned from her position.
Moving forward, the Clinical/Program Supervisor will ensure all documentation relevant to direct/close supervision will occur according to licensing standards and within the required time frames.
This will occur by documenting weekly supervisory sessions to include an hour of direct supervision if the counselor assistant requires "Close Supervision".
All documentation in the client file will be counter signed by the clinical supervisor such as individual/group/ family sessions, treatment plans, case consultations, and aftercare/discharge plans.
These weekly supervisory session will be monitored by the Program Director to ensure they are occurring.
Person responsible: Clinical/Program Supervisor
Person responsible for monitoring: Program Director |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of staff records conducted during the on-site inspection June 25, 2019, the facility failed to document that its counselor assistants were working toward counselor status by the end of the year 2018.
Staff Person #7 was hired as a high school diploma level counselor assistant on August 22, 2018, and was required to provide documentation to the facility by December 31, 2018, of the steps the staff person was taking to achieve counselor status, but at the time of the on-site inspection there was no documentation of how the staff person was working toward achieving counselor status.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Effective 7/8/19, the counselor assistant (Staff person #7) has resigned from her position.
All future hires of a counselor assistant will have documented their movement towards counselor status via a supervisory note with the Clinical/Program Supervisor as well as a letter to the Program Director stating the above. This documentation will be done upon completion of each calendar year until full counselor status is achieved.
Person responsible: Clinical/Program Supervisor
Person monitoring: Program Director |
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 records 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 #5, a counselor, had 6 hours of training on September 11, 2018, and 13 hours of training on April 30, 2019, through May 1, 2019, but there were no staff training reports completed for either of these trainings.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Effective immediately, all staff, upon completion of a training, will submit a copy of their training certificate along with a training evaluation feedback sheet. These will be turned in to the Administrative Assistant within one week of their training date.
Person responsible: Administrative Assistant
Person monitoring: Administrative Coordinator/Program Director |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection conducted on June 25, 2019, the facility failed to ensure that counseling could not be seen from outside of the counseling rooms. The facility ' s group counseling room has windows that allow persons outside of the facility to see into the counseling room.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Program Director will ensure that window coverings, sufficient for the group space, will be purchased by 8/1/19 and installed by the House Manager Supervisor by 8/4/19.
All program staff will be educated, in the next staff meeting scheduled for 7/25/19, as to the need to ensure the group room curtains are secure and functioning to prevent a breach of confidentiality.
Any program staff, when conducting daily facility checks, will ensure that the proper covering is in place and secure.
Person responsible: Program Director/House Manager Supervisor
Person monitoring: Program Director
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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
Base 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
Base 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 project ' s policy and procedure manual reads that preliminary treatment plans must be completed within 7 days of admission for long term residential rehab 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 February 13, 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 #1 was admitted for residential treatment on February 13, 2019, and was an active client at the time of the on-site inspection, but the client ' s preliminary treatment plan was not completed until February 21, 2019.
Client #5 was admitted for residential treatment on October 30, 2018, and was discharged on April 30, 2019, but the client ' s preliminary treatment plan was not completed until November 9, 2018.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Clinical/Program Supervisor will conduct a training with all current clinical staff by 7/30/19 and at the time of clinical new hire orientation, on the time frames of completion of a Biopsychosocial history and assessment as well as the preliminary, comprehensive and updated treatment plans.
Completion of these documents will be monitored by the Clinical/Program Supervisor via monthly chart audits for Continuous Quality Improvement. Discussions regarding compliance and/or non-compliance will continue in supervision with the clinicians as well as performance evaluations as needed.
Client #1's biopsychosocial assessment was completed and entered into the electronic health record as of 7/23/19.
Person responsible: Clinicians/Clinical/Program Supervisor
Person responsible for monitoring: Program Director
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records conducted during the on-site inspection June 25, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in six of six client records.
The clients' rights forms that the clients sign at the facility do not inform the clients of the following: Clients have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records conducted during the on-site inspection June 25, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in six of six client records.
The clients' rights forms that the clients sign at the facility do not inform the clients of the following: Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
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 conducted during the on-site inspection June 25, 2019, the facility failed to document a complete record in three of six client records reviewed during the on-site inspection.
There were six client records out of a total of six client records reviewed during the on-site inspection that required documented physical examinations.
Client #4 was admitted for treatment on September 26, 2018, and discharged on March 26, 2019, but the facility could not provide a documented physical examination for the client.
Client #5 was admitted for treatment on October 30, 2018, and discharged on April 30, 2019, but the facility could not provide a documented physical examination for the client.
Client #6 was admitted for treatment on January 2, 2019, and discharged on February 17, 2019, but the facility could not provide a documented physical examination for the client.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Effective immediately, all client physicals will be completed within the time frames according to Gaudenzia's Policy and Procedures. These will be kept in the client files in the nurses office until discharge when they get archived after two years on-site.
The nurse will coordinate with the counselors to merge the files post-discharge.
Person responsible: Nurse/Counselors
Person responsible for monitoring: Clinical/Program Supervisor/Program Director |
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 25, 2019, the facility failed to document a complete record in one of three applicable client records reviewed during the on-site inspection.
There were three client records out of a total of six client records reviewed during the on-site inspection that required discharged summaries.
Client # 6 was discharged on February 17, 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 Clinical/Program Supervisor will provide a training with all clinical staff by 7/30/19 and upon new hire clinical orientation, as to the forms that are to be utilized and to the fact that Discharge Summaries are to be completed within 7 days of the date of discharge.
Client#6's discharge summary will be completed by 7/26/19 and will be signed off in the electronic health record, by the Clinical Supervisor, that it was completed.
Person responsible: Clinical/Program Supervisor
Person responsible for monitoring: Program Director |