INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 29, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Chester 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 and a plan of correction is due on September 24, 2007.
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Plan of Correction
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709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
The facility failed to include activities and accomplishments of the preceding year for the facility in the 2005-2006 annual report.
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Plan of Correction
The annual report for the FY'07 will be printed and avilable for the current FY and every year thereafter and will include activities and accomplishments for the previous FY.
Person responsible - Director of Development. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
The project failed to include time frames and available resources for the 2007-2008 project goals and objectives.
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Plan of Correction
Executive staff who are responsible for specific goal areas will develop and revise plans in specific goal areas in consultation with their respective Board Committees and available resources for approval at the September Board meeting and every September thereafter. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the facility's policy and procedure and the client records, the facility failed to obtain an informed and voluntary consent in two of six client records reviewed, #1 and 2. Information was released to the funding source without a signed consent by the client for that disclosure.
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Plan of Correction
Clinical Staff has been trained and instructed on the importance of obtaining informed and voluntary consent for release of information. Specifically, releases for a client's funding source will be obtained during the admission process. As of 9/1/07, charts are in compliance and Clinical Supervisor will audit charts monthly to ensure that proper consents are completed. |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on a review of the facility's policy and procedure, the facility failed to provide written procedures for the evacuation and transfer of residents impaired by drugs or alcohol.
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Plan of Correction
There is already a policy in place which addresses the procedure to be followed for the evacuation and transfer of residents impaired by drugs or alcohol. This policy is standard 709.27.1-8, 705.9&10 on page 93 of Gaudenzia's Policy, Procedure, & Plan Manual. It was an oversight on the part of staff for not being able to provide this information at the time of the inspection. An in service training has been conducted, as of 9/4/07, informing staff of this policy and the proper protocol for this situation. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to include proposed support services available to the client on the individual treatment plan in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
Clinical staff has been trained by Clinical Supervisor to include 12-step meeting attendance and identification of sober social supports as part of treatment planning. Additionally, identification of a sponsor and home group will be included as treatment goals. As of 9/1/07, these have been incorporated into treatment plan. Clinical Supervisor will monitor ongoing documentation for the identification of support services. |
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 the facility's policy and procedure and the client records, the facility failed to include documentation on the lack of progress on the treatment plan updates in four of five client records reviewed, #1, 2, 4 and 6. The facility failed to document a treatment plan update for May 2007 in client record #6. The July 2007 treatment plan update in client record #2 was late.
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Plan of Correction
Clinical Staff attended an in house training regarding treatment plan documentation. Clinical Supervisor provided training for the clinicians. The training highlighted the importance of updating treatment plans every thirty days and that treatment plans can not lapse without an update in place. Also, we discussed the importance of discussing a client's lack of progress towards treatment goals and addressing the barriers. Treatment plan documentation has been brought into compliance as of 9/1/07. Clinical Supervisor will audit charts monthly to ensure that documentation is completed in the appropriate timeframe. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client charts, the facility failed to document on the treatment plan that individual counseling was provided in five of six client records reviewed, #2, 3, 4, 5 and 6.
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Plan of Correction
During an in house training by the Clinical Supervisor, clinical staff has been made aware that they need to document the provision of individual counseling on treatment plans. Clinical Supervisor will audit charts monthly to ensure that individual counseling is included on treatment plans. Changes have been made as of 9/1/07. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document an accurate record of services in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. The record of services was pre-dated and did not include the provider's initials. The provider listed was documented as "staff on duty" or "primary counselor."
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Plan of Correction
Clinical staff has also been trained by the Clinical Supervisor on the proper documentation of Records of Service. As of 9/1/07, all Records of Service are completed on an individual basis and include the staff member who provided each service. Clinical Supervisor will monitor this on an ongoing basis. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to develop aftercare goals with time frames in two of three client records reviewed, #5 and 6. Specific time frames for the aftercare goals were missing. Time frames used included "ongoing" and "as needed." An aftercare plan was missing in one of three client records reviewed, #4.
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Plan of Correction
Clinical Staff received training in completion of aftercare documentation. Training was conducted by Clinical Supervisor. They have been made aware of the importance of completing an aftercare plan for every client who leaves treatment and for establishing timeframes for all aftercare goals. As of 9/1/07, aftercare plans are being completed for all clients. Clinical Supervisor will monitor to ensure that aftercare documentation is completed for every client. |
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 document a discharge summary for one of three client records reviewed, #4.
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Plan of Correction
Clinical Staff received training in completion of discharge documentation. Provided by Clinical Supervisor. They have been made aware of the importance of completing a written Discharge Summary for every client who leaves treatment. As of 9/1/07, discharge summaries are being completed for all clients. Clinical Supervisor will monitor to ensure that discharge documentation is completed for every client. |
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 the facility's policy and procedure and the follow-up log book, the facility failed to document follow-up information as per policy in three of three client records reviewed, #4, 5 and 6.
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Plan of Correction
An updated Aftercare Book has been established and is being maintained by one of the Administrators. This Aftercare Book will include follow up information for all client's discharged from active treatment. It will also document follow up contact with aftercare service and/or the client directly within the established timeframe. Clinical Supervisor will monitor the Aftercare Book for conitnued compliance with follow up procedures. |
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
Based on a review of the facility's policy and procedure and client records, the facility failed to document work therapy on the treatment plans in six of six client records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
During an in house training with clinical staff, they have been made aware that they need to document work therapy as part of treatment planning. Clinical Supervisor has provided this training to the clinicians. This has been established as of 9/1/07 and will be overseen by the Clinical Supervisor on an ongoing basis. |
704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the plan and employee census, the facility failed to present a complete plan to the licensing representative at the time of the site visit. Specifically, the clinical supervisor and one counselor were missing from the plan.
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Plan of Correction
The staff roster/staffing plan will be maintained by the Administrative Coordinator. The Program Director will review the staffing plan to ensure that all employees are accurately listed. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of supervision documentation and staff interview, the counselor assistants were not supervised by a full-time clinical supervisor or a full-time counselor. Supervision of the counselor assistants was completed by the facility director.
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Plan of Correction
As of 9/10/07, the Clinical Supervisor position has been filled. As of that date, Clinical Supervisor has begun directly supervising Counselor Assistants and will be responsible for documentation of supervision. In the absence of the Clinical Supervisor, there is a Senior Counselor who is available to fill in. |
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 the facility's policy and procedure and employee records, the facility failed to document an individual training in one of eight employee records reviewed, #2.
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Plan of Correction
An individual training plan has been completed for employee #2 as of 9/4/07 by the Division Director. Program Director will meet with the Division Director during the last week in December to complete the individual training plan for the coming year. The Division Director will be responsible for its completion in the required timeframe. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of employee CPR certifications and the staff schedule, the facility failed to ensure that at least one person trained in these skills was onsite during the hours of operation. Employee #5 was the sole staff person scheduled to work from 8:00 AM until 9:00 AM on July 29, 2007. Employee #5 did not have a current CPR certification, as it had expired in February 2007.
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Plan of Correction
Staff scheduling will be reviewed to ensure that every shift is covered by at least one employee who has CPR certification. In regards to employee # 5, this employee is schedule to attend CPR/First Aid training on 9/19/07. Program Supervisor and Clinical Supervisor will complete scheduling to ensure that all shifts are covered by a staff member who has been CPR certified. Program Director will oversee scheduling. |