INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on June 2, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on July 1, 2010.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the policy and procedure manual, and an interview with the facility director, the facility failed to document a mechanism to collect feedback on completed training in 2 of 3 personnel records as required.
The findings include:
Five personnel records were reviewed on May 4 - 7, 2010.
Three personnel records were required to contain documented feedback forms after the completion of training.
The facility failed to document the feedback forms after the completion of employee training in personnel records # 2 and 4.
The facilities policy states:
All staff members are required to complete a Staff Training Evaluation at the conclusion of all in-house and outside training. Staff Training Evaluation Sheets are to be given to the Program Director.
The facility director confirmed during an interviewed on June 2, 2010 that the (Essential Learning) trainings were complete on-line and feedback forms were not documented.
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Plan of Correction
Program Director and Administrative Co-ordinator will keep calendar of staff trainings and insure filing of Staff Training Evaluations by month's end. Personnel charts will be reviewed ny Program Director each quarter to insure compliance. |
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 and a review of the policy and procedures manual, the facility failed to provide documentation of individual training plans per policy in five of five personnel records reviewed.
The findings include:
Five personnel records were reviewed on May 4 - 7, 2010.
Individual training plans were required in five personnel records.
The facility did not document individual training plans per policy in personnel records # 1, 2, 3, 4, and 5 for the training year from January 1 2009 to December 31 2009.
The facilities policy states:
The Project Director, Program/Clinical Supervisor and/or nurse will provide each clinical, medical, administrative, and support staff member with an individual staff assessment and training plan for completion relative to the new training year.
Each individual training plan should include the staff member's perceived needs, the supervisor's recommendations, and the specific training areas of focus to be pursued, as well as targeted time frames and sources of training. It is the responsibility of the staff member to carryout the agreed upon training plan.
The individual training plan is reviewed and revised annually by the staff member and their supervisor to ensure the training needs are being addressed and met. The employee and the supervisor should each sign the plan.
The plan should be appropriate to the employee's skill level, position and performance requirements and interests. The employee's previous education and experience should also be considered in plan development.
Each plan should identify at least three subject areas for training based on areas needing improvement or goals to be pursued by the employee. It is recommended that, subject areas relate to the core staff training requirements established under Standard 704.1l. d-g, depending on the employee's job title.
Personnel # 1 was hired in 1988.
An individual training plan was documented late on 4/28/10.
Personnel # 2 was hired in 1996.
An individual training plan was documented late on 4/8/10.
Personnel # 3 was hired 7/27/09.
An individual training plan was documented late on 4/27/10.
Personnel # 4 was hired 4/25/05.
An individual training plan was not documented late on 4/27/10.
Personnel # 5 was hired 6/4/04.
An individual training plan was not documented late on 4/8/10.
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Plan of Correction
Program Director will hold a staff meeting each January to complete Individual Training Plans by January 31st each year. Director and Administrative Coordinator will review personnel charts for compliance by February 5th of each year. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant tour, the facility failed to ensure that exits were at least 15 feet apart.
Findings:
The internal stairwells from the second floor to the first floor and the third floor to the second floor run parallel to each other and are separated by a wall. The entrances to the exits are not more than 15 feet apart and the exits are not more than 15 feet apart.
This is a repeat deficiency from the June 18, 2009 inspection.
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Plan of Correction
This deficiency was cited 11/20/09 and a POC approved 5/10/10. The expected completion date for the deficiency is 10/31/2010. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client medical records, and a review of the policy and procedures manual, the facility failed to document physical examinations per facility policy in three of five client records.
The findings include:
Eight client medical records were reviewed on June 2, 2010.
Five records reviewed required documentation of physical examinations.
The facility failed to document physical examinations per policy in client records # 2, 3, and 5.
The facility policy states:
Residents shall have a physical examination performed within the first week of admission. The physical examination will assure that a client is free from communicable diseases or any other medically related concern that would pose a significant obstacle to treatment. In cases where a client has received a verifiable physical examination within one month prior to admission, the program Medical Director or his/her designee shall perform an examination comprised of taking and recording of vital signs and asking the client if significant changes have occurred since his/her last exam.
Client # 2 was admitted to the program on 5/13/10.
The physical examination reviewed in the medical record was dated and signed by a physician on 5/25/10.
The physical examination was documented late, and the physician's impressions/diagnosis was not included in the physical examination at the time of review on 6/2/10.
Client # 3 was admitted to the program on 3/17/10.
The physical examination reviewed in the medical record was partially complete; however, it was not dated, the client's general appearance was not documented, it was not signed by the physician, nor was the physician's impressions/diagnosis included in the physical examination at the time of review on 6/2/10.
Client # 5 was admitted to the program on 3/29/10.
The physical examination reviewed in the medical record was dated and signed by a physician on 3/18/10.
The physical examination was timely, however, the physician's impressions/diagnosis was not included in the physical examination at the time of review on 6/2/10.
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Plan of Correction
Facility nurse will insure compliance with guidelines for having complete client physical within seven days from the date of admission. Facility nurse will review each physical for completeness and have physician complete any missing documentation. This will be added to facility's Quality Improvement Plan and monitored by Program Director monthly. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on the review of client records and a review of the policy and procedures manual, the facility failed to document follow-up information within 7 days from the date of discharge in 1 of 2 client records.
The findings include:
Eight client records were reviewed on June 2, 2010.
Two client records required documentation of follow-up information.
The facility failed to document follow-up within 7 days from the date of discharge, as per facility policy, in client record # 7.
The facility's policy on follow- up states:
Follow Up: Within seven (7) days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate.
In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted directly by the counselor or supervisor ' s designee to determine the client ' s well-being and to maintain the opportunity for re-admission should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge.
Information shall be kept in the follow up log binder.
Client # 7 was admitted to the program on 11/9/09 and discharged on 11/18/09, follow-up was not documented at the time of review on 6/2/10.
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Plan of Correction
Follow-up contact log will be maintained by the Clinical Supervisor for each discharge from the program. Contact will be made within seven days from the date of discharge. Program Director will review log monthly and report out on it in the Facility Monthly Report.
Client #7 did not leave a phone number. In the future if a client leaves ASA, the clinical supervisor will contact the emergency contact number or intensive case manager and note this in the follow up contact log. |