INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 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 Washington 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of two applicable records.
Employee # 3 was hired as a counselor on January 22, 2019 and has remained in that position since. The facility's training year that was reviewed was from January 2021 through December 2021. Employee #3's personnel record only documented 24.85 hours of training for the period reviewed.
Employee # 4 has been in the position of counselor since March 4, 2013. The facility's training year that was reviewed was from January 2021 through December 2021. Employee # 4's personnel record only documented 19.5 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These staff members are both currently on track to complete the required 25 hours of training for the year 2021-2022 according to their individual training plans.
Going forward, the Program Director will ensure that all training hours are completed within required timeframes and according to the annual training plan for each employee. A full review of all trainings will be completed with the clinician and documented in a supervision note at least quarterly to ensure that all staff trainings are up to date, and to ensure that any staff who are nearing the deadline will be scheduled to complete the trainings prior to the due date.
A training grid is completed and sent to the regional office on a quarterly basis to ensure another layer of oversight. If any training issues are noted, these are discussed in the next monthly Directors meeting to be addressed with the Program Director.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on May 26, 2022, the facility failed to ensure that facility heaters were permanently mounted or installed as portable heaters were found in both counselor offices.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The space heater was removed from the facility on 5/26/2022.
Facility staff will monitor for the presence of portable heaters during weekly safety checks, which are documented on a log. Any portable heater will be brought to the immediate attention of the Program Director for removal.
The Program Director will monitor this log on at least a monthly basis.
In addition, the presence of portable heaters will be monitored by the CQI Department during quarterly CQI site inspections and any findings will be reported to the Program Director for immediate removal.
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705.10 (c) (2) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
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Observations
Based on a physical plant inspection on May 26, 2022, the facility failed to ensure that the fire extinguisher in the kitchen be located near an exit, as it was placed directly next to the stove/oven.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/10/22 both an ABC class fire extinguisher and K class fire extinguisher have been mounted in the kitchen area near exit.
Fire Extinguishers are inspected at least monthly by facility staff which is documented on the fire Extinguisher tags and in the safety report. The Program Director will review the safety report each month to ensure compliance.
In addition, fire extinguishers are monitored by the CQI Department during quarterly CQI site inspections and any findings will be reported to the Program Director for immediate action.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from July 2021 through April 2022, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program had been using an older version of the fire drill log which did not have a space to document the exit route utilized for each drill.
On 6/9/22, the Deputy Regional Director forwarded to the Program Director the correct log form which includes documentation of the exit route utilized during the drill.
The Program Director will review the correct form with all staff responsible for documentation of fire drills no later than 6/17/22.
The Quality Assurance Department will conduct at least quarterly audits to include a review of fire drill logs using an auditing tool which includes this as a specific item. Any issues noted will be brought to the immediate attention of the Program Director and will be included on a performance improvement plan.
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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 three of three applicable records reviewed.
Client #1 was admitted on March 17, 2022 and discharged Against Medical Advise (AMA) on April 22, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
Client #3 was admitted on November 18, 2021 and discharged Against Medical Advise (AMA) on January 28, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
Client #4 was admitted on September 23, 2021 and discharged Against Medical Advise (AMA) on December 8, 2021. 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 will be completed for all ASA discharges. This is the responsibility of the primary Counselor for the respective client. If the primary Counselor is not present, then the Program Director will notify the Emergency Contact.
The Program Director will review the policy again with all staff in an in-service training no later than 6/17/22.
The Program Director and will review all client files at time of discharge to ensure that this has been completed. Any chart missing this notification will be brought to the attention of the clinician to make immediate notification to the documented emergency contact.
The Program Director will conduct at least monthly chart audits using our quantitative audit tool, which lists this as a specific item for review.
In addition, the Quality Assurance Department will complete at least quarterly reviews using this same quantitative audit tool. Any findings will result in development of a performance improvement plan to be addressed by the program.
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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 the 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.
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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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four records reviewed. Additionally, the facility failed to keep disclosures of client identifying information with the limits established by Pa Code 255.5 (b) in four unusual incident reports filed with funding sources.
Client #1 was admitted on March 17, 2022 and discharged on April 22, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on March 17, 2022, to whom there was no client signed consent to release information form.
Client #2 was admitted on November 2, 2021 and discharged on March 8, 2022. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on November 2, 2021, November 7, 2021, and November 14, 2021, to whom there was no client signed consent to release information form.
Client #5 was admitted on March 15, 2022 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on March 15, 2022, to whom there was no client signed consent to release information form.
Client #7 was admitted on March 28, 2022 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to a diagnostic laboratory on March 28, 2022, to whom there was no client signed consent to release information form.
Additionally, unusual incidents reported to funding sources on the following dates revealed UDS results or substances of relapse, which exceed the limits established in Pa Code 255.5 (b): August 6, 2021, August 20, 2021, December 22, 2021, and January 11, 2022.
This is a repeat citation from the June 10, 2021 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All current staff members with responsibility for completion of releases will attend the DDAP web-based Drug and Alcohol Confidentiality Training delivered by DDAP. This will be completed by 6/30/22.
In ongoing monthly all-staff meetings this will be a standing agenda item with the Program Director leading an interactive discussion using examples of information which can and cannot be disclosed. This will be documented with a sign-in sheet.
The Program Director will complete at least monthly audits of a sample of charts including a qualitative review of consent forms to ensure that all information to be released is within the established limits. Any issues noted will be brought to the immediate attention of the clinician and corrected within 48 hours.
The Quality Assurance department will conduct quarterly audits which will result in a Performance Improvement Plan developed in collaboration with program management to address any issues identified.
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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 client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in two of four applicable records reviewed.
Client #2 was admitted on November 2, 2021 and was discharged on March 8, 2022. A treatment plan update was completed on February 1, 2022 and another treatment plan update was due by March 1, 2022; however, no additional treatment plan updates were completed prior to the client ' s discharge.
Client #3 was admitted on November 18, 2021 and was discharged on January 28, 2022. A treatment plan update was completed on December 23, 2021 and another treatment plan update was due by January 23, 2022; however, no additional treatment plan updates were completed prior to the client ' s discharge.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Program Director regarding treatment plan updates, and how to properly document this in the record.
The Administrative Assistant will send a reminder to clinicians at the beginning of each month noting which clients are due for Treatment Plan updates. Clinical staff will send all treatment plans to Program Director for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming updated treatment plans will be reviewed in weekly Clinical Staff meeting.
The Program Director will conduct monthly audits of a sample of charts using our quantitative audit tool in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation. conducted by the Clinical Supervisor regarding this regulation, and how to properly document this in the record.
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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. Six of six applicable records reviewed did not indicate that any staff participated in the case consultations.
Client #2 was admitted on November 2, 2021 and was discharged on March 8, 2022. The client record did not contain documentation of case consultation notes that included the names and titles of participants.
Client #3 was admitted on November 18, 2021 and was discharged on January 28, 2022. The client record did not contain documentation of case consultation notes that included the names and titles of participants.
Client #4 was admitted on September 23, 2021 and was discharged on December 8, 2021. The client record did not contain documentation of case consultation notes that included the names and titles of participants.
Client #5 was admitted on March 15, 2022 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes that included the names and titles of participants.
Client #6 was admitted on April 12, 2022 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes that included the names and titles of participants.
Client #7 was admitted on March 28, 2022 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes that included the names and titles of participants.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This will be reviewed with all clinical staff in an in-service conducted by the Program Director no later than 6/17/22.
The Administrative Assistant will send a reminder to clinicians at the beginning of each month noting which clients are due for case consultations. Upcoming case consultations will also be reviewed in weekly Clinical Staff meeting.
The Program Director will conduct monthly audits of a sample of charts in order to ensure that case consultations are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation.
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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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in four of four applicable records reviewed.
Client #1 was admitted on March 17, 2022 and discharged on April 22, 2022. The client record did not contain documentation of follow-up information.
Client #2 was admitted on November 2, 2021 and was discharged on March 8, 2022. The client record did not contain documentation of follow-up information within 30 days, the timeframe for follow-up established in their policy.
Client #3 was admitted on November 18, 2021 and was discharged on January 28, 2022. The client record did not contain documentation of follow-up information.
Client #4 was admitted on September 23, 2021 and was discharged on December 8, 2021. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients will be contacted post-discharge and this contact (or attempt) will be documented in our electronic health record on the Follow Up Contact Note created for this purpose. This will occur within 7 days of the date of the referral appointment for completions, and within 30 days for all other discharges.
This will be the responsibility of the clinician at the program. This will be done by running a discharge report from our electronic health record, and noting which clients require a follow-up contact.
Staff will be re-trained in an in-service no later than 6/17/22 conducted by the Program Director regarding this regulation, and how to properly document follow-up in the record using our Follow-Up Contact form.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements. This includes follow-up post-discharge. The Administrative Assistant will send a reminder to clinicians at the beginning of each month noting which clients are due for follow-up. Upcoming follow-ups will be reviewed in weekly Clinical Staff meeting.
The Program Director will conduct monthly audits of a sample of discharged charts. Any missing documentation will be brought to the attention of the clinician in documented supervision and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The project failed to document, in the client's complete record, verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in four of seven client records reviewed.
Client #1 was admitted on March 17, 2022 and discharged on April 22, 2022.
Client #4 was admitted on September 23, 2021 and was discharged on December 8, 2021.
Client #5 was admitted on March 15, 2022 and was active at the time of the inspection.
Client #6 was admitted on April 12, 2022 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be re-trained in an in-service no later than 6/17/22 conducted by the Program Director regarding this regulation. Program Director will review the treatment plan form, and the specific areas designed to be used to indicate work as treatment as an integral part of the treatment plan.
The Program Director will conduct monthly audits of a sample of charts in order to ensure that treatment plans properly document work as treatment. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Quality Assurance Department will conduct at least quarterly audits to include all Plans of Correction to ensure full implementation.
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