INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 1, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. 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(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the project ' s records submitted to the Department on May 23, 2019, the project failed to follow its comprehensive staff development program for agency personnel.
The overall training plan for the project was not completed until May 16, 2019, but the projects Plan for Assessing Staff Training Needs in the project ' s policy and procedure manual reads, " The training plan shall be ready for implementation effective Jan. 31st of each year. "
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year. |
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 the project ' s policy and procedures manual conducted at the Department ' s headquarters from May 21-24, 2019, the facility failed to follow the project ' s comprehensive staff development program for agency personnel.
The project ' s policy and procedure manual reads, " Each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos, or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/ Clinical Supervisor."
There were no feedback forms for the 12 hours of mandatory training for Staff Person #5, the facility director, for the 2018 training year.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Following a staff attending a training workshop, seminar or in-service training, Staff will submit a copy of training certificate and feedback sheet to Program Administrator.
Upon receipt of feedback sheet and certificate Administrator will complete a tracking form of all received documents, file certificate and feedback sheet in staff personnel file.
Administrator will submit tracking form to Program Director. Program Director will review tracking sheet monthly during staff meeting to ensure all documents are submitted and filed in a timely manner. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Base on a review of the project ' s staff records conducted on June 3-4, 2019, the project failed to ensure that all of its staff had the appropriate fire extinguisher training.
Staff Person #1, the project director, was hired on March 4, 2019, but the staff person did not receive fire extinguisher training.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Base on a review of the project ' s staff records conducted on June 3-4, 2019, the project failed to ensure that all of its staff had the appropriate emergency training.
Staff Person #1, the project director, was hired on March 4, 2019, but the staff person did not receive emergency training.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (d) (3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
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 the project ' s policy and procedure manual conducted at the Department ' s headquarters from May 21-24, 2019, the facility failed to complete its admission and treatment documentation within the time frames adopted by its governing body.
The project ' s policy and procedure manual reads that the biopsychosocial history and assessment must be completed within 5 days of admission for all residential programs.
The facility is a long term residential treatment program, and the project ' s policy and procedure manual reads that individual treatment plans are to be completed 30 days from the date of preliminary treatment plan for long term residential programs.
Client #1 was admitted for residential treatment on December 14, 2018, and was discharged on March 20, 2019. The client ' s preliminary treatment plan was completed on December 14, 2018, but the client ' s individualized treatment plan was not completed until February 11, 2019.
Client #2 was admitted for residential treatment on January 8, 2019, and was discharged on April 8, 2019. The client ' s preliminary treatment plan was completed on January 8, 2019, but the client ' s individualized treatment plan was not completed until March 2, 2019.
Client #2 was admitted for residential treatment on January 8, 2019, but the client ' s biopsychosocial assessment was not completed until January 16, 2019.
Client #3 was admitted for residential treatment on March 14, 2019, and was an active client at the time of the on-site inspection. The client ' s preliminary treatment plan was completed on March 19, 2019, but the client ' s individualized treatment plan was not completed until May 29, 2019.
Client #5 was admitted for residential treatment on April 5, 2019, and was an active client at the time of the on-site inspection. The client ' s preliminary treatment plan was completed on April 8, 2019, but the client ' s individualized treatment plan was not completed until June 6, 2019.
Client #6 was admitted for residential treatment on April 5, 2019, and was an active client at the time of the on-site inspection. The client ' s preliminary treatment plan was completed on April 9, 2019, but the client ' s individualized treatment plan was not completed until May 14, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Upon admission of all clients to the program, Intake Specialist will complete all initial admission forms including biopsychosocial with-in 72 hours of arrival. Intake Specialist will route client's completed chart to Program Supervisor for review to ensure all documents are completed within the designated timeframe accordance to agency policy and procedures. |
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 client records conducted during the on-site inspection July 1, 2019, the facility failed to ensure that it obtained an informed and voluntary consent to release information before it disclosed information from the client records in one of six client records reviewed.
Client #1 was admitted for treatment on December 14, 2018, and discharged on March 20, 2019. The facility billed the client ' s funding source while the client was in treatment, but there was no signed consent to release information for the client ' s funding source.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Upon admission of all clients to the program the Intake Specialist will have client sign all intake documents including consent to release information, for all service providers and responsible parties for clients treatment. Intake Specialist will route completed intake chart to Program Supervisor within designated timeframe to ensure all documents are signed. Program Supervisor will review and report any deficiencies during weekly clinical meetings. Program Supervisor will ensure all corrections are completed with 24 hours of notice to Intake Specialist. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to obtain documentation signed by the clients that it informed the clients of their rights in two of six client records reviewed during the on-site inspection.
The clients sign a form as part of the admission process that documents that the clients have been informed of their rights.
There was no signed client rights form for clients #1 and #4.
These findings were reviewed with facility staff as part of the licensing process.
This is a repeat citation from the June 2, 2017 annual inspection.
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Plan of Correction
Client's Bill of Right form has been incorporated into clients orientation manual. Member will sign form with Intake Specialist and return at the conclusion of the intake. The signed form will become part of the client's record. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process the Client Bill of Right form is signed and included into client chart record. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records conducted during the on-site inspection July 1, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in four of six client records reviewed.
The clients' rights forms that the clients sign at the facility do not inform the clients of the following: That the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
Clients #2, #3, #5 and #6 signed the clients ' rights forms.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records conducted during the on-site inspection July 1, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in four of six client records reviewed.
The clients' rights forms that the clients sign at the facility do not inform the clients of the following: Clients have the right to appeal a decision limiting access to their records to the director.
Clients #2, #3, #5 and #6 signed the clients ' rights forms.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records conducted during the on-site inspection July 1, 2019, the facility failed to acquire documentation from clients that it informed the clients of all of their rights in four of six client records reviewed.
The clients' rights forms that the clients sign at the facility do not inform the clients of the following: Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Clients #2, #3, #5 and #6 signed the clients ' rights forms.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Continuous Quality Improvement Director has revised the Gaudenzia Client Bill of Rights to accurately reflect the DDAP 709.30 regulations regarding a client's right to inspect their own record and actions they make take in this regard. The document now states that, "The following rights are affirmed... The right to examine one's own record within the guidelines approved by the agency in accordance with Federal regulations 42 CFR, and rebut any information in their record by inserting a counter statement of clarification or correction. The agency may temporarily remove portions of the record prior to inspection if the Director determines that the information may be detrimental if presented to the client. Reasons for removal of sections will be documented in the record. Clients have the right to appeal a decision limiting access to their records to the director. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records." This revised Bill of Rights document will be distributed to all programs by 7/26/19. The Program Director will review it with all staff and it will be incorporated into the client orientation manuals and signed by all active clients by 8/2/19. The Program Director will ensure that as a part of the regular, monthly CQI Chart Audit process, the current version of the Client Bill of Rights is being completed. |
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 conducted during the on-site inspection on July 1, 2019, the facility failed to ensure that treatment plans were updated at least once every 30 days in two of five applicable client records.
A total of six client records were reviewed during the on-site inspection, and five of the six records required treatment plan updates.
Client #1 ' s individualized treatment plan was completed on February 11, 2019. The client was discharged on March 30, 2019, but the client ' s treatment plan was never updated.
Client #6 ' s individualized treatment plan was completed on May 14, 2019, but the treatment plan was not updated until June 25, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Program Supervisor has developed a chart audit form for client's records identifying due date of clinical document including treatment plan and updated treatment plan . Program Supervisor will complete a weekly audit of all client's records to ensure all client's records are accurate and current. Program Supervisor will review audit with Program Director in collaboration audit will be reviewed during weekly clinical meeting. Program Supervisor will ensure all correction are completed in a designated timeframe. |