INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on May 23,2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia Focus 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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704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on the review of the staff schedule, the facility failed to have at least one staff person on the premises at all times.
The findings include:
On May 23, 2012, the staff schedules from April 8, 2012 through May 26, 2012 were reviewed. The staff schedule indicated the facility did not have at least one staff person on the premises at all times.
During the month of April 2012, the facility did not have at least one staff person on the premises between the hours of 7:00 AM and 8:00 AM for 15 out of 30 days as follows:
4/9/12, 4/10/12, 4/11/12, 4/12/12, 4/17/12, 4/18/12, 4/19/12, 4/20/12, 4/22/12, 4/23/12, 4/24/12, 4/25/12, 4/26/12, 4/27/12 and 4/30/12.
During the month of May 2012, the facility did not have at least one staff person on the premises between the hours of 7:00 AM and 8:00 AM for 4 out of 22 days as follows:
5/1/12, 5/2/12, 5/3/12 and 5/4/12.
During the month of May 2012, the facility did not have at least one staff person on the premises between the hours of 8:00 AM and 9:00 AM for 7 out of 22 days as follows:
5/7/12, 5/9/12, 5/10/12, 5/11/12, 5/14/12, 5/15/12 and 5/17/12.
An interview with the facility director on May 23, 2012 confirmed the findings.
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Plan of Correction
Project Supervisor will ensure that facility is fully covered by awake staff 24 hours. Division Director will review staff scheduled each month to ensure 24 hour coverage at the facility. Staff will sign in and out according to schedule. If electronic clock is not working there will be a sign in and out sheet for staff to sign before and after each shift. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in one of two records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1's personnel record was reviewed. The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988. Per policy, training plans will be conducted in January of each year. The facility failed to document an individual training plan in January for employee # 1.
The findings were reviewed with the human resources staff.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented with all employees within required timeframes. This will be completed for all employees by January 31, 2013 as per our policy. |
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 the staff schedules and the facility's Cardio Pulmonary Resuscitation (CPR) certification documents and first aid cards, the facility failed ensure that at least one staff person trained in CPR and first aid was onsite during the project's hours of operation.
The findings include:
On May 23, 2012, CPR certification documents and staff schedules from April 8, 2012 through May 26, 2012 were reviewed. The staff schedules indicated the facility did not have at least one staff person trained in CPR and first aid on the premises at all times.
During the month of April 2012, the facility did not have at least one staff person trained in CPR and first aid on the premises between the hours of 7:00 AM and 8:00 AM for 15 out of 30 days as follows:
4/9/12, 4/10/12, 4/11/12, 4/12/12, 4/17/12, 4/18/12, 4/19/12, 4/20/12, 4/22/12, 4/23/12, 4/24/12, 4/25/12, 4/26/12, 4/27/12 and 4/30/12.
During the month of May 2012, the facility did not have at least one staff person trained in CPR and first aid on the premises between the hours of 7:00 AM and 8:00 AM for 4 out of 22 days as follows:
5/1/12, 5/2/12, 5/3/12 and 5/4/12.
During the month of May 2012, the facility did not have at least one staff person trained in CPR and first aid on the premises between the hours of 8:00 AM and 9:00 AM for 7 out of 22 days as follows:
5/7/12, 5/9/12, 5/10/12, 5/11/12, 5/14/12, 5/15/12 and 5/17/12.
An interview with the facility director on May 23, 2012 confirmed the findings.
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Plan of Correction
Program Director and Administrative Assistant will review staff personnel charts one time each quarter for CPR/First Aid compliance. Program Director will ensure all staff is trained and certified in CPR/First Aid to make certain that at least one person trained in these skills is onsite during the project's hours of operation. |
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, the facility failed to store all trash, garbage and rubbish in covered containers.
The findings include:
An inspection of the facility's physical plant was conducted on May 23, 2012 between approximately 1:00 PM and 1:45 PM. At the time of inspection, the trash dumpster was overflowing with trash. The dumpster's lids could not be closed due to the excessive amounts of trash in the dumpster.
An interview with the facility director on May 23, 2012 confirmed the findings.
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Plan of Correction
Program Supervisor and employees of Focus House will make certain that the noncombustible covered container for garbarge and rubbish does not overflow. A lock and chain will be palced on dumpster to prevent overflow, and the penetration of insects and rodents. The removal of trash and rubbish will be done twice weekly. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide soap in each bathroom.
The findings include:
An inspection of the facility ' s physical plant was conducted on May 23, 2012 between approximately 1:00 PM and 1:45 PM. At the time of inspection, the facility failed to provide soap in three of the four client bathrooms. Client bathroom # 1 on the ground floor, client bathroom # 3 on the second floor, and client bathroom # 4 on the third floor did not have soap.
An interview with the facility director on May 23, 2012 confirmed the findings.
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Plan of Correction
House Managers will check all residential bathrooms daily to ensure that all bathrooms have hand soap and or operable soap dispensers at all times. Program Director will make certain that Focus House purchase hand soap or order soap for dispensers to replenish soap for residential bathrooms as needed. |
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 upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant policies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and tp meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Suprvisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis. These policies will be revised and approved by July 31, 2012. |