INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Together 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, qualifications for one employee hired as a counselor could not be determined to meet the regulatory requirements for the position at the time of the inspection.
Employee #8 was hired as a counselor on July 11, 2022 and was current in that position at the time of the inspection. Based on documentation provided by the facility, it could not be determined if the employee had a major in a qualifying field.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The official transcripts for this employee have been reordered and will be uploaded to their file once received. We currently have copies of their unofficial transcript. 8/31/23
Going forward, Human Resources staff will ensure that the official transcript is obtained for all new hires prior to start. The Program Director and/or the Clinical Supervisor will also check to make certain that this is completed, and will coordinate with HR if any issues are noted.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
An initial physical plant inspection was conducted on June 20, 2023, to review all common areas for the onsite licensing inspections for multiple licenses at the physical plant address spanning June 20, 2023 through June 23, 2023. The facility failed to keep frozen food at or below 0 degrees Fahrenheit as the walk-in freezer in the kitchen was 12 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Kitchen Manager will ensure that Freezer temperatures are monitored on a daily basis, and documented in a log. Any issues noted will be brought to the attention of the maintenance department to immediate repair. The freezer was repaired on 6/29/23.
Additionally, Gaudenzia is hiring new Facility Manager for the 1306 Spring Garden Street building to oversee all physical plant areas, including the kitchen.
The QA Manager reviews the physical plant on a quarterly basis, to include Freezer temperatures and logs. Any issues noted will be brought to the attention of the Kitchen Manager for immediate remediation.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
An initial physical plant inspection was conducted on June 20, 2023, to review all common areas for the onsite licensing inspections for multiple licenses at the physical plant address spanning June 20, 2023 through June 23, 2023. The facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company as the fire extinguisher in the basement pantry indicated that the most recent inspection and approval occurred in October 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director alerted the maintenance department on 5/9/2022 who has scheduled the fire extinguisher inspection agency to come to the facility on or before 6/9/2022 to inspect or replace this fire extinguisher as appropriate. 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 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. |
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
Based on a review of eight personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in three applicable records reviewed.
Employee # 2 was hired as the Facility Director on June 13, 2022 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until May 23, 2023.
Employee # 4 was hired as a counselor on January 9, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until May 23, 2023.
Employee # 5 was hired as a counselor on January 20, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until May 23, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and/or RSP Supervisor will ensure that all new hires receive adequate fire safety training within the first 7 days of employment. This will be done by reviewing all new hire requirements with each new employee at the end of their first 5 days of employment. Any staff who have not yet had the training at that point will receive it immediately.
This will be documented in the staff file for each employee.
The Program Director will perform a quarterly review of Individual Training Plans to double-check that this was completed for all staff. Any staff found to be out of compliance will be trained immediately.
QA department will perform a quarterly review of Individual Training Plans to confirm that this was completed for all staff. Any issues noted will be brought to the attention of the Program Director for immediate action.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from July 2022 through June 2023, the facility failed to conduct unannounced fire drills at least once a month. There were no fire drills conducted in July, August, or October 2022 on the third floor. There was no fire drill conducted on the sixth floor in July 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and/or Recovery Support Professionals will conduct unannounced monthly fire drills on each shift. The Recovery Support Supervisor will ensure that each drill is documented in the logbook monthly.
The Program Director will review Fire Drill Logs/Reports prior to the end of each month to ensure that this has been completed.
The QA department will perform a quarterly review of Fire Drill documentation. Any issues noted will be brought to the attention of the Program Director for immediate action.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from July 2022 through June 2023, the facility failed to ensure that fire drill logs included the exit route used and whether the smoke detector or fire alarm was operative for each fire drill conducted. The exit route was missing on the logs from November 2022, April 2023, May 2023, and June 2023 for the third floor and from the August 2022 and November 2022 logs for the sixth floor. Documentation of whether the smoke detector or fire alarm were operative was missing from the fire drill log from August 2022 for the sixth floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will provide staff with an example of a completed fire drill log, which they will be required to fill out themselves to ensure proper documentation. This will occur during an in-service training staff meeting no later than 8/18/23.
The Program Director will review Fire Drill Logs/Reports prior to the end of each month to ensure that this has been completed.
The QA department will perform a quarterly review of Fire Drill documentation. Any issues noted will be brought to the attention of the Program Director for immediate action.
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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 eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 6 was admitted on May 25, 2023 and was active at the time of the inspection. The consent to release information form to the funding source was not signed until May 29, 2023, and there was evidence of billing prior to the client signed consent to release information form.
Client # 8 was admitted on May 16, 2023 and was active at the time of the inspection. The consent to release information form to the funding source was not signed until May 19, 2023, and there was evidence of billing prior to the client signed consent to release information form.
This is a repeat citation from the June 16, 2022, June 24, 2021, and October 6, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review the requirements regarding Confidentiality and Releases of Information with all staff during staff in-service no later than 8/18/23. This training will include review of the standard workflow, and reference the specific forms in our EHR.
In addition, the Program Director and Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The QA department will monitor confidentiality and releases of information during quarterly CQI file audits and will report findings to the Program Director.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of eight client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client #2 was admitted on December 23, 2022 and was discharged for non-adherence on December 29, 2022. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
This is a repeat citation from the June 16, 2022 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review the requirements regarding Treatment Termination Notification with all staff during staff in-service no later than 8/18/23. This training will include review of the standard workflow, and reference the specific form in our EHR.
In addition, the Program Director and Clinical Supervisor will monitor this area during monthly file audits and address discrepancies during staff supervisions.
The QA department will monitor this area during quarterly CQI file audits and will report findings to the Program Director.
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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 eight client records, the facility failed to document treatment plan updates within the regulatory timeframe in one of two applicable records reviewed.
Client # 4 was admitted on July 26, 2022 and was discharged on September 13, 2022. The individual treatment and rehabilitation plan was completed on August 7, 2022, and the treatment plan update was due no later than September 7, 2022; however, the update was not completed prior to the client ' s discharge.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Treatment Planning training will be delivered to all clinical staff by the QA Director no later than 8/18/23.
In addition, the Program Director and Clinical Supervisor will monitor this area during monthly file audits and address discrepancies during staff supervisions.
The QA department will monitor this area during quarterly CQI file audits and will report findings to the Program Director.
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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 records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in five of seven applicable records reviewed.
Client # 1 was admitted on August 2, 2022 and was discharged on September 19, 2022. The treatment plan completed on August 28, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session between September 9, 2022 and the date of discharge.
Client # 4 was admitted on July 26, 2022 and was discharged on September 13, 2022. The treatment plan completed on August 7, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between August 7, 2022 and August 21, 2022.
Client #5 was admitted on January 30, 2023 and was discharged on February 22, 2023. The treatment plan completed on January 31, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between February 6, 2023 and the date of discharge.
Client # 6 was admitted on May 25, 2023 and was active at the time of the inspection. The treatment plan completed on May 29, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between May 29, 2023 and June 12, 2023.
Client # 7 was admitted on May 31, 2023 and was active at the time of the inspection. The treatment plan completed on June 3, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between June 3, 2023 and June 13, 2023.
This is a repeat citation from the June 16, 2022, June 24, 2021, and October 6, 2020 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Staff will post their session schedules on the unit to help ensure that no sessions are missed.
Treatment Planning training will be delivered to all clinical staff by the QA Director no later than 8/18/23.
In addition, the Program Director and Clinical Supervisor will monitor this area during monthly file audits and address discrepancies during staff supervisions.
The QA department will monitor this area during quarterly CQI file audits and will report findings to the Program Director.
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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 ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary, in three of five applicable records reviewed.
Client #2 was admitted on December 23, 2022 and was discharged on December 29, 2022. There was no documentation of a discharge summary in the record.
Client #3 was admitted on January 26, 2023 and was discharged on February 13, 2023. There was no documentation of a discharge summary in the record.
Client #5 was admitted on January 30, 2023 and was discharged on February 22, 2023. There was no documentation of a discharge summary in the record.
This is a repeat citation from the June 16, 2022 and June 24, 2021 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will review the requirements regarding completion of Discharge Summaries with all staff during staff in-service no later than 8/18/23. This training will include review of the standard workflow, and reference the specific form in our EHR.
In addition, the Program Director and Clinical Supervisor will monitor this area during monthly file audits and address discrepancies during staff supervisions.
The QA department will monitor this area during quarterly CQI file audits and will report findings to the Program Director.
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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 # 2 was admitted on December 23, 2022 and was discharged on December 29, 2022. There was no documentation of follow-up information in the record.
Client # 3 was admitted on January 26, 2023 and was discharged on February 13, 2023. There was no documentation of follow-up information in the record.
Client # 4 was admitted on July 26, 2022 and was discharged on September 13, 2022. There was no documentation of follow-up information in the record.
Client # 5 was admitted on January 30, 2023 and was discharged on February 22, 2023. There was no documentation of follow-up information in the record.
This is a repeat citation from the June 16, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This will be completed by the Primary Clinician or designee for all discharge individuals within the required timeframes.
The Program Director will review the requirements regarding Follow Up with all staff during staff in-service no later than 8/18/23. This training will include review of the standard workflow, and reference the specific form in our EHR.
In addition, the Program Director and Clinical Supervisor will monitor this area during monthly file audits and address discrepancies during staff supervisions.
The QA department will monitor this area during quarterly CQI file audits and will report findings to the Program Director.
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709.14(b)(3) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(3) Change in location of the facility.
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Observations
Based on an administrative review of documents and a physical plant inspection, the facility failed to notify the Department within 90 days of a change in the location of the facility. The facility is licensed to operate on the third, fourth, and sixth floors of the building; however, it is only operating on the sixth floor of the building and the other licensed floors for this license are being utilized for other programs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Division Director in consultation with the Director of Regulatory Standards will submit the required documentation to DDAP no later than 8/31/23.
In the future, the Division Director will ensure that DDAP will be made aware of any such changes in location within the 90-day timeframe.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the June 16, 2022, June 24, 2021, and October 6, 2020 annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the June 21, 2023 licensing inspection.
A plan of correction for providing counseling services according to the treatment plan was submitted and approved by the Department for the June 16, 2022, June 24, 2021, and October 6, 2020 annual licensing inspections. Providing counseling services according to the treatment plan was again found to be a deficiency in the June 21, 2023 licensing inspection.
A plan of correction for ensuring a complete client record included a discharge summary was submitted and approved by the Department for the June 16, 2022 and June 24, 2021 annual licensing inspections. Completing discharge summaries was again found to be a deficiency in the June 21, 2023 licensing inspection.
A plan of correction for providing written notification of involuntary discharge to clients was submitted and approved by the Department for the June 16, 2022 annual licensing inspection. Providing written notification of involuntary discharge was again found to be a deficiency in the June 21, 2023 licensing inspection.
A plan of correction for ensuring a complete client record included follow-up information was submitted and approved by the Department for the June 16, 2022 annual licensing inspection. Completing follow-up information was again found to be a deficiency in the June 21, 2023 licensing inspection.
A plan of correction for ensuring an individual treatment plan is completed according to the facility policies was submitted and approved by the Department for the June 16, 2022 annual licensing inspection. Completing individual treatment plans was again found to be a deficiency in the June 21, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Ultimately, the Program Director will be responsible for implementation of all Plan of Correction Items.
The Program Director will complete monthly reviews of all POC items to ensure that they have been, and continue to be implemented. Any issues noted will be addressed with the appropriate party in a documented supervision session and corrected within 48 hours.
In addition, the Quality Assurance department will conduct quarterly audits of the program, which include reviews of any open POCs. Any issues noted will be brought to the immediate attention of the Program Director to be addressed as noted above.
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