INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2009 and May 19, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. West Chester 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 June 22, 2009.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of case load assignments, personnel records, interviews and a review of the staffing requirements facility summary report, the drug and alcohol project failed to provide a full-time clinical supervisor for every eight full-time counselors.
Findings:
Gaudenzia Inc. West Chester is staffed by three full time counselor assistants and five full-time counselors. A review of the staffing requirements summary report completed by the facility director for the survey and an interview with the facility director and clinical supervisor on May 19, 2009 at 13:45 verified that the clinical supervisor is assigned four residents and does not have the time necessary to supervise the three full-time counselor assistants and five full- time counselors.
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Plan of Correction
The policy has been reviewed and the caseloads have been reassigned. It has been clarified that at no time will the Clinical Supervisor maintain a client caseload greater than one client due to her supervision responsibilities of the other clinicians. The Program Director will monitor for compliance. However, the Division Director is responsible to approve for the hiring of any new staff. If the Program Director is unable to maintain compliance due to a shortage of staff, the Division Director will be notified so that compliance can be maintained or to have fee for service clinicians approved by the Division Director. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on a physical plant inspection of the facility, the licensee failed to notify the Department of an increase in the authorized capacity.
Findings:
The facility is authorized for a maximum capacity of 65 residents. Resident living areas are located on the second floor of the facility. A physical plant inspection of the second floor on May 19, 2009 between the hours of 10:00 A.M. and 11:15 A.M. revealed that the facility had 68 beds set-up. An interview and discussion with the facility director, clinical director and an administrative assistant on May 19, 2009 at 13:30 provided additional verification of the 68 beds located on the second level of the facility.
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Plan of Correction
The maximum bed capacity for GHWC remains at 65 beds. Although there were 68 beds set up at the time of the site inspection, this was an error and an oversight. There were not 68 clients in treatment. As of the inspection date (5/18/09) the additional beds have been taken down and removed from the facilty premises. Program Supervisor will monitor for compliance. In the absence of a Program Supervisor, the Program Director will monitor for compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of resident medical records and an interview with the facility director and clinical supervisor, the agency failed to document physical examinations within seven days of the admission date.
Findings:
Intake and admission procedures reviewed on May 5, 2009 and May 6, 2009 require resident physical examinations be completed or documented in the resident medical record within seven day of admission. Based on a review of eleven resident medical records on May 18, 2009 and May 19, 2009 and an interview with the facility director and clinical supervisor on May 19, 2009 at 13:30, the agency failed to document physical examinations in four of eleven records within seven days of admission.
Client record # 1: Admitted on January 22, 2009. Medical record reviewed on May 18, 2009 between the hours of 10:00 and 14:30. The physical examination in the medical record did not include a dated physician's signature.
Client record # 3: Admitted on February 19, 2009. Medical record reviewed on May 18, 2009 between the hours of 10:00 and 14:30. The physical examination reviewed in the medical record was dated and signed by the physician on April 3, 2009. The physical examination was thirty-six days late based on the established physical examination documentation procedures.
Client record # 7: Admitted on December 31, 2008. Discharged March 5, 2009. Medical records reviewed on May 19, 2009 between the hours of 09:30 and 13:00. The physical examination reviewed in the medical record was dated and signed by the physician on January 27, 2009. The physical examination was documented twenty days late based on the established physical examination documentation procedures.
Client record # 10: Admitted on March 9, 2009. Discharged April 13, 2009. Medical record reviewed on May 19, 2009 between the hours of 09:30 and 13:00. The physical examination reviewed in the medical record was dated and signed by the physician on March 23, 2009. The physical examination was documented seven days late based on the established physical examination documentation procedures.
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Plan of Correction
A staff meeting with the medical department was held on 5/20/09. It was clarified that the Nurse Manager is to be the gatekeeper for the department and she needs to ensure that physical exams are completed within the established timeframe. Additionally, the Nurse Manager is aware that if the medical department will not meet the deadline, she is to notify the Program Director prior to the passing of the deadline so that we can make arrangements to schedule an appointment so that the deadline can be met. As a backup measure, we have also identified an outside agency that will be able to conduct physical exams in an emergency situation. |