INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 22, 2020 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, Gaudenzia, Inc. West Chester was found not 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of five staff qualifications on December 22, 2020, the faciltiy failed to ensure that each counselor shall met at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
Staff # 3 was hired on March 2, 2020. Staff #3 had a Bachelor's degree in Psychology and did not have one year of clinical experience in a health or or human service agency.
Staff # 4 was hired on November 23, 2020. Staff #4 had a Bachelor's degree in Psychology and did not have one year of clinical experience in a health or or human service agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An addendum to these staff member's training plans will be completed by the Program Director specifying how, during the course of their supervisory period, they will receive the required supervision and gain the required experience as described in DDAP regulation 704.7(b). This addendum will be completed by 02/05/21. Moving forward, the Program Director will ensure that all Counselor Assistants have applicable training plans that will conform to staffing qualification standards. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical site inspection on December 22, 2020. The facility failed to maintain the furnishings in the living room in a state of good repair.
A majority of the couches and love seats had rips in them.
These findings were reviewed with faciltiy staff during the licensing process.
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Plan of Correction
Program Director had submitted a purchase order for new furniture, however, there have been delays in ordering/receiving due to COVID-19 restrictions. As of 01/26/21, a new purchase requisition was signed by Regional Director and has been submitted to the Purchasing Department. Program Director will work with Purchasing Department to ensure timely delivery of furniture. Quality Assurance Department will conduct quarterly physical site audits to ensure that the facility and furniture is in good repair. |
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 a physical plan inspection conducted on December 22, 2020, the faciltiy failed to ensure privacy so that counseling sessions could not be seen or heard outside the counseling room.
While reviewing client records in the physician's office, an intake could be heard that was being conducted in another office in the same hallway area.
Also, a private discussion with the Faciltiy director, client and staff/counselor could also be overheard in the same hallway.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from a licensing inspection that took place on January 31, 2020.
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Plan of Correction
Program Director spoke with staff in a staff meeting on 01/21/21 regarding client privacy and confidentiality, reminding staff to utilize sound machines, to ensure that conversations are held in private areas, and to close doors when providing services. Moving forward, during daily facility checks, Program Director or designee will ensure client sessions/interactions are held privately and that sound machines are used appropriately. The Quality Assurance Department will review confidentiality practices, including the use of sound machines, during quarterly onsite facility audits. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
During a onsite inspection on December 22, 2020, the facility failed to notify the Department of a change in activity within the ninety day timeframe requirement.
The facility has been prescribing Buprenorphine for more than ninety days without approval from the Department.
These findings were reviewed with faciltiy staff during the licensing process.
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Plan of Correction
The Eastern Region office has re-submitted the application on 1/27/21 to specify an appropriate number of persons (15) to be treated in order to meet the required ratios for the use of buprenorphine. In the future, the program will ensure that it is licensed for all services which it provides. The Quality Assurance department will conduct quarterly reviews which will include monitoring of all licensed activities to ensure compliance.
Gaudenzia West Chester will not prescribe Suboxone until the waiver has been completed. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on seven out of seven client records reviewed on December 22, 2020, the facility failed to provide a consent to release form to the client limiting the information to be released within the limits of 4 Pa. Code 255.5 (b).
Client # 1 was admitted on September 30, 2020 and was still an active client at the time of the inspection. A consent to release form to a funding agency dated September 30, 2020 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 2 was admitted on September 28, 2020 and was still an active client at the time of the inspection. A consent to release form to a funding agency and probation officer dated September 28, 2020 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 3 was admitted on October 13, 2020 and was still an active client at the time of the inspection. A consent to release form to a funding agency dated October 13, 2020 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 4 was admitted on October 28, 2020 and was still an active client at the time of the inspection. A consent to release form to a funding agency dated October 28, 2020 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 5 was admitted on June 23, 2020 and was discharged on August 6, 2020. A consent to release form to a funding agency and probation officer dated June 23, 2020 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 6 was admitted on May 7, 2020 and was discharged on July 27, 2020. A consent to release form to a funding agency dated May 7, 2020 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
Client # 7 was admitted on September 11, 2020 and was discharged on November 2, 2020. A consent to release form to a funding agency dated September 1, 2020 allowed for the release of psychological/psychiatric evaluations, treatment plans, case consultations, mental health, physical, and medical records, progress notes, and assessments.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from licensing inspections on January 31, 2020.
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Plan of Correction
Program Director met with clinical team regarding confidentiality requirements during a clinical team meeting on 01/22/21. In addition, as of 01/01/21, the form in the electronic health record has been revised to now prompt clinicians to permit/restrict disclosures based on PA 255.50 requirements. The Program Director will conduct clinical chart audits twice per month and the Quality Assurance Department will conduct quarterly clinical charts audits to review for compliance with all confidentiality requirements. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the medication storage area during a physical site inspection on December 22, 2020, the facility failed to follow their procedures related to disposal of medications for clients that are no longer at the facility.
The facility had a box of Sublocade that was a previous client's medication. The Nursing Staff confirmed that this medication was being held for any incoming client that needed it.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medication noted during onsite audit was disposed of on 12/22/20 by the Health Services Coordinator per program policy. Moving forward, all medications will be disposed of per program policy by the Health Services Coordinator (in the presence of another staff member) within 24 hours post-discharge. The Health Services Coordinator will conduct monthly medication room inspections to ensure that medications are properly disposed of. |
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 seven client records, the faciltiy failed to review and update treatment and rehabilitation plans every thirty days.
Client # 1 was admitted on September 30, 2020 and was current at the time of the inspection. Client #1 had treatment plans on October 1, 2020 and October 31, 2020. Client #1 should have had another treatment plan no later than November 30, 2020 however did not have another Treatment plan update until December 19, 2020.
Client # 4 was admitted on October 28, 2020 and was current at the time of the inspection. Client #4 had a treatment plan on October 29, 2020. Client #4 should have had another treatment plan no later than November 29, 2020 however did not have any other Treatment plans documented in the record.
Client # 5 was admitted on June 23, 2020 and was discharged on August 6, 2020. Client #5 had a treatment plan on June 23, 2020. Client #5 should have had another treatment plan no later than July 23, 2020 however did not have any other Treatment plans documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director met with clinical team regarding treatment plan timeframes during a clinical team meeting on 12/23/20. Moving forward, the Program Director will conduct clinical chart audits twice per month and the Quality Assurance Department will conduct quarterly clinical charts audits to ensure that treatment plans and reviews are being developed/reviewed within the required timeframes.
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