INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gratitude House, was found to not 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(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
The facility failed to provide a sufficient number of staff persons trained in CPR certification and first aid training so that at least one person trained in these skills is onsite during the project's hours of operation. The Non-Hospital Rehabilitation facility is operable twenty four hours per day/seven days per week. Employee #6 was hired as a Behavioral Health Tech on 1/28/2004 and does not have First Aid and CPR Certification. Employee #7 was hired as a Behavioral Health Tech on 5/22/2018 and does not have First Aid and CPR Certification. These two staff were the only 2 staff covering the 4 pm to midnight shift on Friday, June 29, 2018 and Friday, July 6, 2018. In addition, Employee # 7 was the only staff covering from 10 pm to midnight on Friday, June 22, 2018. The facility failed to have sufficient coverage. These findings were reviewed with facility staff during the licensing process. This was a repeat citation from the October 30, 2017 inspection.
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Plan of Correction
Employee #6 and #7 completed CPR training on July 25,2018.
Program Director and BH Tech Supervisor will ensure that all shifts are covered by at least one employee who is CPR/first aid certified. Program Director and BH Tech Supervisor will monitor compliance via obtaining a copy of all employees CPR/first aid cards and comparing these to the staff schedule on a monthly basis. Any employee who is due for CPR/first aid recertification will be scheduled by BH Tech Supervisor and reminded of the training. BH Tech Supervisor will follow up with Human Resources following each training to ensure that the employee completed the required training. |
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
The facility failed to update the treatment plan every 30 days in four out of seven client charts. Client #2 was admitted on January 15, 2018 and had a treatment plan update on March 22, 2018. The next treatment plan update was due no later than April 22, 2018, however it was not completed until April 30, 2018. The following treatment plan was due no later than May 30, 2018 however was not completed until June 14, 2018. Client # 4 was admitted on May 14, 2018 and had a treatment plan completed on May 21, 2018. The treatment plan update was due no later than June 21, 2018, however was never completed. The client was discharged on July 9, 2018. Client # 6 was admitted on February 20, 2018 and had a treatment plan update on March 27, 2018. The next update was due no later than April 27, 2018 however was not completed until May 18, 2018. Client #7 was admitted on January 22, 2018 and had a treatment plan update on March 27, 2018. The next update was due no later than April 27, 2018 however was not completed until May 6, 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director conducted a clinical training on July 15,2018 to review treatment plan regulations and current deficiencies. All current clinical staff attended the training. Program Director and Lead Counselor will monitor ongoing progress and compliance through monthly chart audits. Ongoing issues regarding compliance will be addressed individually with clinicians during their monthly supervision. The next chart audits will be conducted by August 31,2018. |
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
The facility failed to provide counseling services according to the individual treatment plan. Client #1 was admitted on May 8, 2018 and the treatment plan dated June 14, 2018 indicated group therapy two times per week. The facility failed to provide two group sessions the weeks of June 17, 2018, June 24, 2018 and July 8, 2018. Client #2 was admitted on January 15, 2018 and the treatment plans dated April 30, 2018 and June 14, 2018 indicated group therapy two times per week and individual therapy bi-weekly. The facility failed to provide two group therapy sessions the weeks of May 6, 2018, May 13, 2018, May 20, 2018 and May 27, 2018. The facility failed to provide two individual therapy sessions in the month of June 2018. Client #3 was admitted on May 3, 2018 and the treatment plans dated May 8, 2018 and June 8, 2018 indicated group therapy two times per week. The facility failed to provide two group therapy sessions the weeks of May 6, 2018, May 13, 2018, June 3, 2018, June 17, 2018 and June 24. 2018. Client #4 was admitted on May 14, 2018 and the treatment plan dated May 21, 2018 indicated group therapy two times per week. The facility failed to provide two group therapy sessions the weeks of May 20, 2018, May 27, 2018, June 3, 2018, June 10, 2018, and June 24, 2018. Client #5 was admitted on January 2, 2018 and the treatment plans dated January 10, 2018 and February 6, 2018 indicated individual session bi-weekly. The facility failed to provide two individual sessions in February 2018. Client #6 was admitted on February 20, 2018 and treatment plans dated February 26, 2018, March 27, 2018 and May 18, 2018 indicated group therapy two times per week and individual therapy bi-weekly. The facility failed to provide two group therapy sessions the weeks of March 4, 2018, April 8, 2018, April 15, 2018, April 29, 2018, May 6, 2018, May 13, 2018, May 20, 2018 and May 27, 2018. The facility failed to provide two individual sessions in the month of April 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Lead Counselor will ensure that group therapy is provided weekly and individual sessions are provided bi-weekly, via monthly chart audits. Clinicians will document reasons if a client misses group due to being at work or dr apt. etc. indicating the reason for missed group that week. Lead Counselor will review any ongoing issues with clinicians during monthly supervision. |