INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 07, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc., Vantage 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(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the Project failed to ensure that each counselor assistant completed at least 30 clock hours of annual training following the first year of employment in one of one personnel records reviewed.
The findings include:
The Project ' s training calendar runs from January 1 to December 31.
One personnel record requiring documentation of 30 clock hours of annual training was reviewed from April 17, 2014 to April 18, 2014. The Project failed to provide documentation of 30 clock hours of annual training in the personnel record of employee # 3 from the Vantage House facility.
Employee # 3, a counselor assistant, was hired on October 26, 2009. Personnel record # 3 only included 25 clock hours of annual training for 2013.
The findings were confirmed during an interview with the Training Institute Department Manager on April 18, 2014 at approximately 11:00 A.M.
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Plan of Correction
As per licensing regulations, the following training requirements for counselor assistants will be adhered to: (1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as: (i) Pharmacology. (ii) Confidentiality. (iii) Client recordkeeping. (iv) Drug and alcohol assessment. (v) Basic counseling. (vi) Treatment planning. (vii) The disease of addiction. (viii) Principles of Alcoholics Anonymous and Narcotics Anonymous. (ix) Ethics. (x) Substance abuse trends. (xi) Interaction of addiction and mental illness. (xii) Cultural awareness. (xiii) Sexual harassment. (xiv) Developmental psychology. (xv) Relapse prevention. (h) Training hours. Training hours are not cumulative from one personnel classification to another.
Person Responsible: Program Supervisor
Person responsible for the monitoring:
Program Director
Full Compliance 5/20/2014
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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 personnel records, the Facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of one personnel record reviewed.
The findings include:
One personnel record was reviewed that required documentation of fire extinguisher training were reviewed during the Administrative Review from April 17, 2014 to April 18, 2014.
Employee #4 was hired as a counselor on August 26, 2013. The employee did not complete fire extinguisher training until September 30, 2013.
The findings were confirmed during an interview with the Training Institute Department Manager on April 18, 2014 and the Facility Director on May 07, 2014.
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Plan of Correction
As per licensing regulations, staff members will receive and the administrative coordinator will ensure training is completed and document fire extinguisher training upon staff employment for every new staff member within their first two days of employment.
Person Responsible: Administrative Coordinator
Person responsible for the monitoring:
Program Director
Full compliance: 5/20/2014 |
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
Based on a review of personnel records, the Facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of one personnel records reviewed.
The findings include:
One personnel record requiring documentation that personnel had been trained to perform assigned tasks during emergencies was reviewed from April 17, 2014 to April 18, 2014. The Facility failed to ensure that their employee had completed emergency training prior to working their first shift.
Employee #4 was hired as a counselor on August 26, 2013. The employee did not complete emergency training until September 30, 2013.
The findings were confirmed during an interview with the Training Institute Department Manager on April 18, 2014 and the Facility Director on May 07, 2014.
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Plan of Correction
As per licensing regulation 705.10. Fire safety. (d) Fire drills. The residential facility shall. Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Emergency training including Fire Safety and Fire Drills will be coordinated by the Administrative Coordinator. The administrative coordinator will ensure that this training is completed for every new staff member within their first two days of employment.
Person Responsible: Administrative Coordinator
Person Responsible for the monitoring:
Program Director
Full compliance: 5/20/2014 |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual in ten of ten client records reviewed.
The findings include:
Ten client records requiring a complete client record, to include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan and/or documentation of follow-up information, were reviewed on May 7, 2014. The facility did not provide a complete client record for client #s 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
Client #1 was admitted to treatment on 12/09/2013 and was still active at the time of the on-site inspection. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #2 was admitted to treatment on 02/20/2014 and was still active at the time of the on-site inspection. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #3 was admitted to treatment on 04/04/2014 and was still active at the time of the on-site inspection. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #4 was admitted to treatment on 03/13/2014 and was still active at the time of the on-site inspection. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #5 was admitted to treatment on 12/17/2013 and was still active at the time of the on-site inspection. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #6 was admitted to treatment on 10/01/2013 and was discharged 01/13/2014. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #7 was admitted to treatment on 10/04/2013 and was discharged 12/20/2013. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #8 was admitted to treatment on 05/09/2013 and was discharged 10/30/2013. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection. Additionally, client follow-up was to be completed no later than 11/30/2013; however, there was no follow-up documented as of the date of the inspection.
Client #9 was admitted to treatment on 06/25/2013 and was discharged 11/16/2013. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Client #10 was admitted to treatment on 07/18/2013 and was discharged 01/02/2014. The facility failed to document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
The Facility Director confirmed the findings.
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Plan of Correction
As per licensing regulations, the facility will document on the individual treatment and rehabilitation plan that work done by the client at the project is an integral part of their treatment and rehabilitation plan as of the date of the inspection.
Person responsible: Program Supervisor
Person responsible for monitoring: Program Director
Full Compliance: 5/7/2014 |