INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 19 - 20, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. People With Hope/Short-Term Program 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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704.10 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 personnel records, the facility failed to ensure that each counselor assistant documented to the facility director that they were working toward counselor status in one of two records reviewed.
The findings include:
On May 19, 2015, two counselor assistant personnel records were reviewed. The facility failed to ensure employee # 4 was working toward counselor status upon completion of the calendar year.
Employee # 4, a high school level counselor assistant was hired June 20, 2011. The facility failed to ensure employee # 4 was working toward counselor status upon completion of the calendar year. In addition, during last years inspection the facility documented, "During this training year in review employee # 4 has not taken any academic credits toward obtaining his degree. "
As such, this is a repeat deficiency as the facility was out of compliance during the April 24, 2014 inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of People with Hope will ensure that counselor assistants hired will satisfactorily complete one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) before they are promoted to the position of counselor.
On June 4, 2015, Counselor #4 resigned from People with Hope because they were unable to meet the qualifications per Division of Drug and Alcohol Licensure per DOH Policy 704.10: Counselor Assistant Promotion.
In the future, if we hire a counselor assistant this information will be documented and updated upon completion of each calendar year by the director and counselor assistant.
Persons Responsible:
Division Director
People with Hope Program Director and Supervisor
Timeframe for Completion: May 28, 2014
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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 personnel records and a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that all staff persons received at least 4 hours of TB/STD training.
The findings include:
Two personnel records requiring documentation of at least 4 hours of TB/STD training were reviewed on May 19, 2015. The facility failed to ensure all staff persons received at least 4 hours of TB/STD training; specifically employee # 4, a counselor assistant.
Employee # 4, a counselor assistant was hired June 20, 2011. TB/STD training was to be completed within the first year of employment or by June 20, 2012. The facility failed to ensure employee # 4 completed TB/STD training at the time of inspection on May 19, 2015.
In addition, the facility documented on the Staffing Requirements Facility Summary Report form that employee # 4 did not complete the training.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The People With Hope (PWH)/Short Term Program will ensure that all staff persons hired shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training using a DDAP approved curriculum per DDAP policy 704.11(c)(1)Mandatory Communicable Disease Training.
Although they were scheduled to take the TB/STD training, on June 4, 2015 Counselor #4 resigned from PWH.
PWH and Short Term Counselors and Counselor Assistants will receive the training within the first year of employment and all other staff will complete the training within the first 2 years of employment.
All staff training plans will be completed with staff at the employee's hire and annually. The staff files will be monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance and completion by the Program Director.
Persons Responsible:
Division Director
Human Resources
PWH/Short Term Program Director
PWH/Short Term Supervisor
Timeframe for Completion: July 3, 2015
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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, the facility failed to comply with the limitations imposed by 4 Pa. Code 255.5 for an informed and voluntary consent for the disclosure of information in four of fourteen client records reviewed.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Fourteen client records requiring documentation of informed and voluntary consents were reviewed on May 19 - 20, 2015. The facility failed to obtain an informed and voluntary consent to release and/or failed to adhere to the limitations imposed by 255.5 in client records, # 3, 8, 13, and 14.
Client # 3 was admitted to the facility on April 2, 2015, and was still an active client at the time of inspection.
1. On April 2, 2015, client # 3 signed a consent to release that did not contain an expiration date or document the agency or organization to whom disclosure would be made. This consent to release also documented the release of "everything" which does not comply with the stipulations of 4 Pa. Code 255.5.
2. On April 2, 2015, the facility faxed information to a governmental agency which exceeded the limitation of 255.5 as the consent to release documented the release of "substance currently being used, frequency, and route."
3. On April 15, 2015, client # 3 signed a consent to release form. The consent to release was not signed by a witness; the client was not offered a copy of this release; and the release failed to document what information would be disclosed.
Client # 8 was admitted to the facility on January 21, 2015 and discharged on May 8, 2015. On February 27, 2015, the facility faxed clinical documents to a non-Gaudenzia drug and alcohol treatment provider regarding client # 8; however, the facility failed to obtain consent to release from client # 8 before the information was faxed.
Client # 13 was admitted to the facility on December 19, 2014 and discharged on December 18, 2014. The facility utilized an outdated insurance form; thus on December 22, 2014, the facility released information that exceeded 255.5 as they released client # 13's medications and type of substances used.
Client # 14 was admitted to the facility on March 4, 2015 and discharged on March 19, 2015. Client # 14 was referred to a non-Gaudenzia drug and alcohol treatment provider; however, the facility failed to obtain consent to release from client # 14 before information was released to this provider.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The People With Hope (PWH)/Short Term Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the chart.
On July 17, 2015 a Record-Keeping training will be facilitated to review the Confidentiality Request to Release Information Form and DOH Policy 709.28(c)and PA Code 255.5. Projects and Coordinating Bodies: Disclosure of Client-Oriented Information.
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
PWH/Short Term Program Director
PWH/Short Term Supervisor
Timeframe for Completion: July 17, 2015
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record.
The findings include:
Fourteen client records were reviewed on May 19 - 20, 2015. The facility failed to document a complete client record that included a record of services provided, case consultations, and/or that work done by the client is an integral part of the treatment and rehabilitation plan in fourteen of fourteen client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14.
Client # 1 was admitted to the facility on March 19, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 2 was admitted to the facility on March 12, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided, and documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 3 was admitted to the facility on April 2, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included a record of services provided, and documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 4 was admitted to the facility on February 24, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 5 was admitted to the facility on February 24, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 6 was admitted to the facility on February 5, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included documentation that work done by client is an integral part of the treatment and rehabilitation plan.
Client # 7 was admitted to the facility on March 31, 2015 and discharged on May 8, 2015. The facility failed to document a complete client record for client # 7 which included a record of services provided, and documentation that work done by client was an integral part of the treatment and rehabilitation plan.
Client # 8 was admitted to the facility on January 21, 2015 and discharged on May 8, 2015. The facility failed to document a complete client record for client # 8 which included a case consultation note and documentation that work done by client was an integral part of the treatment and rehabilitation plan.
Client # 9 was admitted to the facility on February 20, 2015 and discharged on April 13, 2015. The facility failed to document a complete client record for client # 9 which included documentation that work done by client was an integral part of the treatment and rehabilitation plan.
Client # 10 was admitted to the facility on December 19, 2014 and discharged on March 31, 2015. The facility failed to document a complete client record for client # 10 which included documentation that work done by client was an integral part of the treatment and rehabilitation plan.
Client # 11 was admitted to the facility on May 6, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included documentation that work done by is an integral part of the treatment and rehabilitation plan.
Client # 12 was admitted to the facility on on May 8, 2015, and was still an active client at the time of inspection. The facility failed to document a complete client record which included documentation that work done by is an integral part of the treatment and rehabilitation plan.
Client # 13 was admitted to the facility on December 19, 2014 and discharged on December 18, 2014. The facility failed to document a complete client record for client # 13 which included documentation that work done by client # 13 was an integral part of the treatment and rehabilitation plan.
Client # 14 was admitted to the facility on March 4, 2015 and discharged on March 19, 2015. The facility failed to document a complete client record for client # 14 which included documentation that work done by client # 14 was an integral part of the treatment and rehabilitation plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The People With Hope (PWH)/Short Term Program will document a complete client record which will include a record of services that are provided to the client, documentation of case consultations, and/or work that is done by the client which is an integral part of the treatment and rehabilitation plan of Gaudenzia's Therapeutic Community (TC).
On July 17, 2015 a Record-Keeping training will be facilitated to review the DDAP DOH Complete Client Record Policy 709.53(a).
All client records will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings to ensure compliance, completion, and timelines per Policy 709.53 (a) by the Program Director and/or Supervisor.
Persons Responsible:
Division Director PWH/Short Term Program Director PWH/Short Term Supervisor
Timeframe for Completion: July 17, 2015
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