INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 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 Kindred 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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704.7(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 personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee #5 was hired as a counselor on May 9, 2022 and was current in that position at the time of the inspection. At the time of hire, the employee had a qualifying bachelor's degree, but only 1,280 hours of clinical experience, not the required minimum of 1,820 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We are submitting an exception request for this employee. If denied by the Department, employee will be transferred into a position she meets full qualifications for by 8/12/22. This standard was reviewed with the Program Director on 7/18/22. All employment candidate resumes for clinical positions will be reviewed by the Regional Deputy Director and Executive Director for credentialing approval, prior to an offer
of employment being made. The Human Resources dept will oversee the process of ensuring employees with the correct credentials are hired for a specific position, as part of onboarding. In the mean time, the Clinical Supervisor will review and sign off on all documents submitted by the counselor in question. In addition, the Clinical Supervisor will co-facilitate all group and individual sessions. A system is being developed to ensure the Human resources dept is reviewing credential requirements and supervision requirements for existing employees on an ongoing basis |
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 on June 23, 2022, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom as neither were in client bedroom # ' s 2, 5, and 6. Additionally, there were no paper towels in the women ' s restroom on the first floor of the Nelson Center.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will submit a request to maintenance to have mechanical dryers installed throughout the facility. This will occur no later than 7/28/22. Program Director will follow up on this request on a regular basis to receive status updates. Anticipate these being installed by 10/31/22. Paper towels were placed in holder 6/23/22. Furthermore, the presence of paper towels will be added to the daily run sheet by 7/5/22. This will help to ensure that no bathroom is without paper towels, including in the Nelson Center. A weekly review of the run sheets will be completed by the Program Director. Any issues identified will be immediately addressed. The Division Director will complete a monthly review of all plan of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews. The Quality Assurance department will conduct at least quarterly reviews of the program, including all plan of correction items to ensure compliance
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill log from August 2021 through April 2022, the facility failed to ensure that fire drill logs included the exit route used in each drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program was using an outdated version of the form which did not address this item. The program is using the current form as of 7/13/22. A weekly review of the run sheets will be completed by the Program Director. Any issues identified will be immediately addressed. The Division Director will complete a monthly review of all plan of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews. The Quality Assurance department will conduct at least quarterly reviews of the program, including a plan of correction items to ensure compliance. |
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 June 23, 2022, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks. The bathroom in client bedroom # 2 contained two bottles of cleaning products that were not secured with safety latches or locks.
This is a repeat citation from the June 2, 2021 and September 24, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All hazardous materials will be stored in a locked cabinet. Program will establish a Sign-out sheet for all hazardous materials to document every time a client needs to use any potentially hazardous cleaning product. This will be established no later than 7/28/22. A weekly review of the sign-out sheets will be completed by the Program Director. Any issues identified will be immediately addressed. Hazardous materials will also be monitored through daily run sheets. A weekly review of the run sheets will be completed by the Program Director. Any issues identified will be immediately addressed. The Division Director will complete a monthly review of all plan of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews. The Quality Assurance department will conduct at least quarterly reviews of the program, including all plan of correction items to ensure compliance. |
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 on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client #2 was admitted on December 9, 2021 and discharged Against Staff Advice (ASA) on May 15, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
This was noted in a chart from December 2021. This procedure is being completed regularly now. Plan of Correction: At the end of each shift, the counselor will notify emergency contact for any client who left ASA during that shift. This will be documented in the shift log in addition to completing a progress note in the client's chart. Our upgraded Incident Reporting System provides a specific space to document whether the emergency contact was notified. This serves as another reminder to completed notification. The Program Director will conduct a shift log review each day to ensure that no notifications were missed during that day, and will follow up immediately with clinicians to make notification if any had been missed. The Division Director will complete a monthly review of all plan of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews. The Quality Assurance department will conduct at least quarterly reviews of the program, including all plan of correction items to ensure compliance. Documented in independent progress note. |
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 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. Target Date: 9/30/22 |
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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three records reviewed.
Client #1 was admitted on January 6, 2022 and was discharged on March 14, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on January 13, 2022, January 19, 2022, January 28, 2022, February 4, 2022, and February 9, 2022, to whom there was no client signed consent to release information form.
Client #2 was admitted on December 9, 2021 and was discharged on May 15, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on January 6, 2022, January 9, 2022, and December 11, 2021, to whom there was no client signed consent to release information form.
Client #4 was admitted on December 8, 2020 and was discharged on December 9, 2021. The client signed consent to release information form to the funding source expired on September 27, 2021 and there was evidence of billing through the client ' s discharge.
This is a repeat citation from the June 2, 2021 and September 24, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/22/22 This has been corrected for all current clients who did not have this completed in their charts. Going forward a specific release will be completed for all lab work. Program Director will meet with all staff to review this expectation no later than 7/28/22. The Program Director will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note. The Division Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above. The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above. |
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 the facility's written plan for the coordination of client treatment and rehabilitation services, the facility's written procedures for the management of treatment/rehabilitation services for clients indicated that staff names and titles would be included as part of case consultation documentation. Additionally, the policy indicates that case consultations would occur quarterly in the first year of treatment. This documentation missing in four of seven applicable records reviewed.
Client #2 was admitted on December 9, 2021 and discharged on May 15, 2022. The only case consultation note in the record was completed on December 20, 2021 and it did not include the required documentation of participants.
Client #3 was admitted on August 5, 2021 and discharged on September 23, 2021. The case consultation note in the record was completed on September 16, 2021 and it did not include the required documentation of participants.
Client #4 was admitted on December 8, 2020 and was discharged on December 9, 2021. Case consultation notes completed on April 27, 2021 and October 27, 2021 did not include the required documentation of participants.
Client #5 was admitted on February 9, 2022 and was active at the time of the inspection. The case consultation notes completed on March 3, 2022 and June 19, 2022 did not include the required documentation of participants.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, all case consultations will be routed to all participants for signature. The Program Director will meet with all staff to review this expectation, no later than 7/28/22. The Program Director will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note. The Division Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above. The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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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 a discharge summary completed within seven days of discharge in two of four applicable records reviewed.
Client #1 was admitted on January 6, 2022 and was discharged on March 14, 2022. The client record did not contain documentation of a completed discharge summary.
Client #2 was admitted on December 9, 2021 and discharged on May 15, 2022. The client record did not contain documentation of a completed discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Discharge summaries will be completed within 7 days for all discharged clients. The Program Director will meet with all staff to review this expectation, no later than 7/28/22. The Program Director will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note. The Division Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above. The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of client records, the facility failed to follow their written client follow-up policy in three of four applicable records reviewed.
Client #1 was admitted on January 6, 2022 and was discharged on March 14, 2022. The client record did not contain documentation of follow up information with the client within 30 days of discharge.
Client #2 was admitted on December 9, 2021 and discharged on May 15, 2022. The client record did not contain documentation of follow up information with the client within 30 days of discharge.
Client #4 was admitted on December 8, 2020 and was discharged on December 9, 2021. The facility failed to document the results of a follow up attempt in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, the clinician will contact clients who have been discharge within 7 days of their appointment for any referrals, or within 30 days for all other types of discharges, as appropriate. The Program Director will meet with clinicians to review this expectation, and the specific form utilized to document this contact in our electronic health record. The Program Director will complete at least bi-weekly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any incomplete or missing documentation will be brought to the attention of the staff member and corrected within 48 hours. This will be documented in a supervision note. The Division Director will complete at least monthly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Program Director to be addressed with staff as noted above. The Quality Assurance department complete at least quarterly audits of a sample of clinical charts using our Quantitative and Qualitative audit tools. Any issues noted will be brought to the attention of the Deputy Regional Director and Program Director to be addressed with staff as noted above. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(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.
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Observations
Based on a physical plant inspection and a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the June 2, 2021 and September 24, 2020 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the June 23, 2022 licensing inspection.
A plan of correction for securing all hazardous and poisonous substances and materials with safety latches or locks was submitted and approved by the Department for the June 2, 2021 and September 24, 2020 annual licensing inspections. Unsecured hazardous substances was again found to be a deficiency in the June 23, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director, as overseen by the Deputy Regional Director is ultimately responsible for ensuring that the plan of correction is implemented. In addition to the monthly chart audits conducted by the Program Director and Clinical Supervisor, and the quarterly chart audits conducted by the CQI department, the Division Director will also complete monthly audits that specifically address the deficiencies in the plans of correction. These findings will be developed into a report and reviewed with the Program Director. Any discrepancies will be addressed with the appropriate clinical staff and appropriate action taken to ensure compliance. Program will establish a Sign-out sheet for all hazardous materials to document every time a client needs to use any potentially hazardous cleaning product. This will be established no later than 7/28/22. A weekly review of the sign-out sheets will be completed by the Program Director. Any issues identified will be immediately addressed. Hazardous materials will also be monitored through daily run sheets. A weekly review of the run sheets will be completed by the Program Director. Any issues identified will be immediately addressed. The Division Director will complete a monthly review of all plan of correction items to ensure that they are fully implemented, and the Deputy Regional Director will complete quarterly reviews. The Quality Assurance department will conduct at least quarterly reviews of the program, including all plan of correction items to ensure compliance. |