INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. - Winner 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 21, 2009.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of five personnel and training records on June 18, 2009, the facility failed to document that counselors and counselor assistants completed a minimum of 6 hours of HIV/Aids and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment.
Findings:
Five personnel and training records were reviewed on June 18, 2009. One out of five personnel and training records lacked documentation to verify that the mandatory training was completed within the required timeframe.
The facility failed to document a minimum of 6 hours of HIV/AIDS training for employee #4 as of the ending date of this licensing inspection. Employee #4 was hired on May 5, 2008.
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Plan of Correction
Employee #4, the counselor for whom documentation of HIV/AIDS training is missing was registered for6 hours of HIV/AIDS training on 9/29/09.
However, Employee #4 has resigned and is no longer with Gaudenzia.
All new hires of Gaudenzia are now automatically assigned by the Training Department and the WINNER Clnical Supervisor to Core trainings, including TB/STD and HIV/AIDS, on hire. Program Director and Clinical supervisor will ensure attendance at these trainings.
Program Director will review current employees' training records and make sure that any hires (in first or second year of employment, as non-clinical staff) who have not been trained in HIV/AIDS and TB/STD are scheduled for these trainings in the remainder of 2009 to meet regulations.
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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.
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Plan of Correction
Gaudenzia will meet the standard for fire doors. Gaudenzia will retain the architect and engineer who were involved in the renovations to provide Gaudenzia with a solution to the 15 foot exit issue.
This will be accomplished by 10/15/09.
Director of Fiscal and Corporate Operations will be responsible. |
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 the review of eight client records, six of which were reviewed for treatment plan updates, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in five of six client records reviewed.
Findings:
Eight client records were reviewed on June 18, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in six client records. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan in client records #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Inservice will be held by Program Director to instruct counselors on treatment plan updates re: proper documentation of assessment of client's progress in relationship to the stated goals of the prior treatment plan. Weekly chart audits will be conducted by the program director to ensure compliance. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of eight client medication records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include medication records in three of eight client records.
Findings:
Eight client records were reviewed on June 18, 2009. Medication records were required in eight client records. The facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include medication records in client records #4, 6 and 7.
In client record #4, the facility failed to document the client's missed administration of Colace on 6/12 and 6/17/09.
In client record #6, the facility failed to document the client's missed administration of Advair on 3/22 and 4/24/09 and the missed administration of Cogentin on 3/22/09.
In client record #7, the facility failed to document the client's missed administration of Geodone on 5/9/09.
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Plan of Correction
RN will provide inservice training for all House Managers who accompany patients during self-administration of medications. Proper documentation will be covered in this inservice. Weekly medical chart audits will be conducted by the program director to ensure compliance. A power point presentation on medication administration will be given to each employee and to new hires. |
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 eight client records, four of which required documentation that follow-ups had been completed, the facility failed to document follow-up information in two of four client records where required.
Findings:
Eight client records were reviewed on June 18, 2009. Follow-up information was required in four client records. The facility failed to document follow-up information in client records #6 and 7.
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Plan of Correction
Administrative Coordinator will receive inservice provided by Intake/Aftercare Specialist re: proper documentation of follow-up information for clients after discharge. The Program Director will conduct weekly chart audits to ensure compliance and will incorporate this requirement into the staff supervision sessions. |