INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2019 of Gaudenzia Inc. by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudeniza Inc. 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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704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual, the facility failed to follow their policy in regard to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated, "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16th, 2019.
These findings were reviewed with facility staff during 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. |
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 personnel files, employee #1 was not trained in the use of the fire extinguisher upon employment. Employee #1 was hired on March 19, 2019 and was still employed at the time of the inspection. There was no documentation that he employee received the training as of the date of this inspection June 11, 2019.
The findings were reviewed with facility staff during 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.
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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
Based upon a review of personnel files, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 19, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1's personnel file indicating that the employee had been trained on what to do during emergencies as of the date of this inspection on June 11, 2019.
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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. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of seven client records, the facility's client rights documentation, included in the orientation packet, failed to include all the required client rights. The facility failed to include that:
Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall 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.
These findings were reviewed with facility staff during 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. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of seven outpatient client records, there was no documentation that the clients received counseling services according to their individual treatment and rehabilitation plan in three charts reviewed.
Client #1 was admitted on October 17, 2018 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, dated April 12, 2019, indicated one individual session per week. The chart's record of service and progress notes indicated that the client had received only one individual session in April and two in May.
Client #2 was admitted on July 2, 2018 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, dated January 31, 2019, indicated one group session per week and one individual session per week. The client's record of service and progress notes indicated that the client had received only one group session in January, February, March, April and May.
Client #3 was admitted on December 20, 2018 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, dated March 23, 2019, indicated one individual session per week. The client's record of service and progress notes indicated that the client had received only two individual session in March, April and May.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be
held on Sept 13, 2019 by Program Supervisor and Division Director to address clinical staff on treatment
management procedures specific to counseling services must match the individualized treatment plan and treatment plan updates. The Program Supervisor will direct all clinical staff to schedule clients in the EHR system according to their treatment recommendation. This will be documented weekly on the EHR client
record of service. Any deviation
from the set course of treatment will
be documented by the clinician on the record of service. The Program Supervisor, Clinical Superivisor and Division Director will
review treatment plans
recommendations and compare it to
the record of service for compliancy
during the CQI process monthly.
Clinical staff will be monitored
monthly in regular supervisory
sessions as well as weekly during
clinical meeting.
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