INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Winner Co-Occurring Women and Children 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on May 24, 2022, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as one trash receptacle outside of the rear of the building was full and uncovered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/25/22, the dumpster was emptied and covered. An assigned House Manager will conduct a daily facility inspection that will include ensuring the trash receptacle outside of the rear of the building is emptied and secured. This will be documented on the facility run sheets.
Building inspections will be conducted at least weekly by the Director and assigned staff. Audits will be conducted using Monthly Safety and Sanitization Report and will be reported during monthly staff meetings. Any identified issues that immediately impact the health and safety of the clients will be immediately reported to the Program/Division Director and the appropriate work orders submitted to the Maintenance Department.
The Division Director will monitor this standard through monthly DDAP POC audits.
The facility will have at minimum quarterly onsite facility audits that will be conducted by the organization's CQI Department staff. Findings will be documented using the CQI Manager Quarterly Program Review and Audit Preparation Tool. Findings will be immediately discussed with program management onsite at the conclusion of the audit. Findings will also be reported and documented in the monthly Eastern Region CQI Meetings. The Division Director or her designee will be responsible for ensuring that all work orders are completed in a timely manner.
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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
Based on a review of four personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one applicable record reviewed.
Employee #3 was hired as a Clinical Supervisor on February 28, 2022 and was due to be trained in the use of fire extinguishers by March 7, 2022; however, fire safety training was not documented as complete until March 20, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will complete all required Fire Safety and Fire Extinguisher training within required timeframes, as delineated in 705.10.
The Program Director will ensure that all staff complete these trainings within seven days of employment. At the 5th day, a review of all training requirements will be done so that any that have not been met can be attended to before the 7th day.
The trainings will be conducted by the Program Director/designee with each employee as part of the orientation process on-site. This will be documented in the employee's file.
The Division Director will monitor this standard through monthly DDAP POC audits.
The Quality Assurance department will conduct a review of all Plans of Correction to ensure full implementation of all action steps.
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705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on a physical plant inspection on May 24, 2022, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks. A room on the second floor labeled " Boy ' s Bathroom " contained cleaning products and equipment and was unlocked when checked twice during the inspection. The door to the staff office in the basement childcare area was open, and the room contained three cans of paint.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 25, 2022, the door to the room on the second floor has had an automatic lock installed and the sign labeled "Boy's Bathroom" has also been removed. On June 24, 2022, the paint in childcare area was removed. Staff will monitor these and other hazards in hourly safety checks throughout the program which are documented on the run sheet. These are reviewed by the House Manager Supervisor and/or Program Director weekly to ensure that these are happening as scheduled and accurately documented.
The Division Director will monitor this standard through monthly DDAP POC audits.
In addition, the Quality Assurance Department conducts quarterly reviews of the physical plant as well as reviews of corrective action plans to ensure full implementation of all action steps.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project's last annual financial audit was for the years ending June 30, 2020 and 2019.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Annual Financial Audit for the most recent fiscal year (FY 2020 ? 2021) was not completed in a timely manner due to the delays on the part of the independent certified public accounting firm.
Among these delays were the application of new standards regarding the review of all leased properties (to include all real estate, business machines, and vehicles). This was a very laborious process that will not need to be repeated in the future.
Gaudenzia will obtain a completed financial audit from the independent certified public accounting firm on or before September 30th of 2022.
In order to help ensure that these delays do not occur in the future, the reorganized Fiscal department will begin preparation of all possible documents required for the audit as early as possible in the year.
Leadership in this department reviewed the regulations in DDAP 709.25 on 4/26/22 in order to ensure that all understand the importance of timely completion of the Financial Audit.
The Chief Financial Officer will oversee this process.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that personnel records contained a reviewed and signed annual written staff performance evaluation in one of three applicable records reviewed.
Employee # 4 has been in the counselor position since April 20, 2020 and is current in that position. The annual written staff performance evaluation for the 2021 calendar year period was not completed by the supervisor or signed and dated by the employee as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 had a written annual performance evaluation completed on 2/2/21 for the 2021 calendar year. This was in the employee's file, but Program Director failed to submit the evaluation during the DDAP visit.
Going forward, the human resources department and Division Director will ensure that these documents are completed, signed and presented for all inspections.
The Program Director position is currently vacant, however this will be reviewed by the Division Director with the new Program Director, once hired, to ensure that this is not an issue in the future.
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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.
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Observations
Based on a review of seven records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in six records reviewed.
Client #1 was admitted on December 8, 2021 and was discharged on February 10, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on January 25, 2022 and December 8, 2021, to whom there was no client signed consent to release information form.
Client #2 was admitted on September 10, 2021 and was discharged on April 11, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on March 7, 2022, to whom there was no client signed consent to release information form.
Client #3 was admitted on October 26, 2021 and discharged on January 5, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on December 30, 2021 and October 26, 2021, to whom there was no client signed consent to release information form. Additionally, the record contained documentation that personally identifying information was released to the Department of Human Services on October 26, 2021, with no consent to release information form signed by the client.
Client #4 was admitted on August 20, 2021 and was discharged on December 24, 2021. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on October 20, 2021, to whom there was no client signed consent to release information form.
Client #5 was admitted on December 26, 2021 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on May 13, 2022, to whom there was no client signed consent to release information form.
Client #7 was admitted on December 20, 2021 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on March 7, 2022, to whom there was no client signed consent to release information form.
This is a repeat citation from the July 7, 2021 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of June 23, 2022, client #5 and client #7 signed a consent to release information to the diagnostic laboratory.
On June 24, 2022, the Division Director will conduct an in-service training regarding informed and voluntary consent from the client for disclosure of information contained in the client records.
Moving forward, the Program Director/Clinical Supervisor will conduct bi-weekly clinical chart audits to ensure that the consent forms are appropriately completed with the required information to be disclosed to the identified person/organization. All audits will be conducted and documented using our auditing tools. Any issues identified will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
The Division Director will monitor this standard through monthly DDAP POC audits.
Additionally, the Quality Assurance department will conduct quarterly audits to ensure conformance to documentation standards of 709.28, and will conduct a review of the Plan of Correction in order to ensure full implementation of all action steps.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the unusual incident log, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving a physical or sexual assault by staff or a client.
On January 20, 2022, two clients were involved in a physical altercation. A written unusual incident report was not filed with the Department.
This is a repeat citation from the July 7, 2021 annual licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of June 16, 2022, the incident on January 20, 2022 involving two clients in a physical altercation was submitted to DDAP.
All unusual incidents will be reported to and reviewed daily by the program director or their designee, including timely submission of reports to DDAP. The Program Director/Clinical Supervisor will ensure that all reportable incidents incident reports are completed and signed within 24 hours, and that DDAP-reportable incidents are submitted to DDAP within the regulatory timeframe as required by standard 709.34(c) (1). The Program Director or designee will also inform the Women & Children's Division Director of all DDAP-reportable incidents within 24 hours of the incident. In addition, all incidents will be uploaded to Gaudenzia's Internal Incident Portal System, which has been upgraded with a mechanism to remind Program Directors to submit Unusual Incident Reports to DDAP for all incidents falling within relevant categories.
Additionally, the Quality Assurance department will conduct quarterly audits to include review of all incidents, and will conduct a review of the Plan of Correction in order to ensure full implementation of all action steps.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in two of six applicable records reviewed.
Client #6 was admitted on January 24, 2022 and was active at the time of the inspection. The comprehensive treatment plan was completed on March 7, 2022 and a treatment plan update was due by April 7, 2022; however, the next update was not completed until April 14, 2022.
Client #7 was admitted on December 20, 2021 and was active at the time of the inspection. The comprehensive treatment plan was completed on January 19, 2022 and an update was due by February 19, 2022; however, the next update was not completed until March 8, 2022. The next treatment plan update was due by April 8, 2022; however, the next update was not completed until May 18, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective May 30, 2022, client treatment plans will be reviewed and discussed, including upcoming treatment plan reviews during monthly clinical meetings/supervisions.
The Clinical Supervisor will review all active client treatment plans to ensure that all plans are being updated every 30 days.
The Clinical Supervisor/Program Director or designee, will run clinical scorecard at least weekly from our electronic health records system to monitor treatment plan due dates.
In addition, the Program Director/Clinical Supervisor will conduct bi-weekly clinical chart audits to ensure that all treatment plan updates are completed. All audits will be conducted and documented using our auditing tools. Any issues identified will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
In addition, the Division Director will conduct monthly audits and the Quality Assurance Department will conduct quarterly reviews.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including case consultation notes in three of five applicable records reviewed.
Client #5 was admitted on December 6, 2021 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes after December 28, 2021, and they should have been completed at least quarterly per the facility's policy.
Client #6 was admitted on January 24, 2022 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes after February 4, 2022, and they should have been completed at least quarterly per the facility's policy.
Client #7 was admitted on December 20, 2021 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes, and they should have been completed at least quarterly per the facility's policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 24, 2022, the Division Director will conduct an in-service training with the clinical staff regarding documentation of case consultation notes.
In addition, the Program Director/Clinical Supervisor will conduct bi-weekly clinical chart audits to ensure that all case consultation notes are completed. All audits will be conducted and documented using our auditing tools. Any issues identified will be addressed with the clinician in a documented clinical supervision session, and corrected within 48 hours.
The Quality Assurance department will conduct quarterly audits to ensure conformance to documentation standards of 709.53(a)(8), and will conduct a review of the Plan of Correction in order to ensure full implementation of all action steps.
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