INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 4 & 5, 2008 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 July 9, 2008.
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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 upon a review of twelve personnel records on May 16, 2008 and June 5, 2008 the facility failed to ensure that all staff hired as counselors met the qualifications for the position. Five of the twelve staff members reviewed were counselors and of those five, one did not meet the educational requirements.
Employee #5 did not have a qualifying degree.
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Plan of Correction
Credentials and degree for employee #5 were submitted to Division of Drug and Alcohol Program Licesure for qualification approval. The requested approval has been received and indicates that employee #5 does hold a degree qualifying him for his position.
Clinical Supervisor and Program Director will review the degree of all applicants in order to ensure that the degree qualifies him/her for the position. If it does not meet the qualifying degrees listed in the standards or the licensing alert from 2002, the facility will submit it to the Division of Drug and Alcohol Program Licesure for review prior to hiring the individual.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based upon a review of twelve personnel records on May 16, 2008 and June 5, 2008 the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
Staff person #12 (intern serving as a counselor) has a start date of 12/01/06 and had not completed the training as of the exit date of the visit.
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Plan of Correction
Staff person #12 (intern serving as counselor) has been scheduled to attend HIV/AIDS training 8/20/08. This will bring her into compliance.
The Clinical Supervisor will complete required training registration documentation to ensure that all newly hired clinical staff are scheduled for all mandatory trainings within the first 30 days of employment. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based upon a physical plant inspection conducted on June 4 & 5, 2008, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. One dumpster had a broken lid on June 5, 2008 and the lids were left open on both dumpsters on June 4, 2008.
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Plan of Correction
The issue with the dumpsters has been resolved as of 6/6/08. A new dumpster has been delivered to replace the dumpster with a broken lid. Additionally, all staff and clients have been instructed on the importance of keeping the lids closed at all times. Staff members have been informed that they need to check the dumpsters while making hourly grounds runs. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based upon a review of twelve personnel records on May 16, 2008 and June 4, 2008 the facility failed to instruct one of twelve staff in the use of the fire extinguisher within seven days from the start of employment. Employee #5 was hired in October of 2007 and had not received training as of the exit date of this visit.
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Plan of Correction
Employee #5 was transferred to GHWC without having received fire extinguisher training within the first seven days of employment with the agency. This employee is currently out of the office on FMLA. Upon his return to employment, this employee will attend an in-service training in order to bring him into compliance in this area.
Clinical Supervisor will ensure that all newly hired clinical staff recieve an in house fire extinguisher training within the first 72 hours of employment. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of twelve personnel records on May 16, 2008 and June 4, 2008 the facility failed to instruct one of twelve staff in the emergency procedures within seven days from the start of employment. Employee #5 was hired in October of 2007 and had not received training as of the exit date of this visit.
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Plan of Correction
Employee #5 was transferred to GHWC without having received emergency procedures training within the first seven days of employment with the agency. This employee is currently out of the office on FMLA. Upon his return to employment, this employee will attend an in-service training in order to bring him into compliance in this area.
Clinical Supervisor will ensure that all newly hired clinical staff recieve an in house emergency procedure training within the first 72 hours of employment. |
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 upon a review of seven client records on June 5, 2008 the facility failed to obtain informed consents to release information in seven of seven records reviewed.
Seven of seven client records contained medical release forms that stated the information would be released to a laboratory of the facility's choice. This format does not meet the requirements for an informed consent.
Two of seven client records reviewed, specifically client records #2 & 3, contained consent to release information forms signed by the client and facility witness that lacked to whom the information was to be released, what was to be released and the purpose of the release.
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Plan of Correction
An in-service training is scheduled for 7/16/08 with the clinical staff as well as the administrator who is responsible for completing the initial consents with clients upon their admission to treatment. During this in-service, the Clinical Supervisor will review the importance of all informed consents and the proper completion of each document.
Clinical Supervisor will oversee and monitor clinical records in order to ensure that all necessary consents are appropriately completed. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based upon a review of seven client records on June 5, 2008 including the medical records, the facility failed to follow the facility policy and procedure stating "If a client is unavailable or refuses to take medication at the correct time, the nurse shall circle and initial the med sheet and document in the comments section the reason the medication was not given".
The required documentation was missing from four of six client records where documentation of medications was required, specifically client records #2, 4, 5, 6 & 7.
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Plan of Correction
An in-service training will be conducted during the next monthly staff meeting in order to ensure that all staff are appropriately trained on the protocol for medication administration including the appropriate notations to be utilized when a client is unavailable or refuses to take medications.
The Nurse Manager will review all Medication Administration Records(MAR)on a weekly basis for the next three months to ensure compliance, if at the end of the three month period all MARs are found to be in compliance, the Nurse Manager will pull MARs randomly on a quarterly basis to ensure continued 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 upon a review of seven client records on June 4 & 5, 2008 the facility failed to provide physical examinations in accordance with facility policies and procedures.
Physical exams in two of seven records had not been completed within seven days of admission,.
Client #2 was admitted on 5/19/08 and did not receive a physical examination until 5/28/08.
Client #3 was admitted on 3/7/08 and did not receive a physical examination until 3/21/08.
One of seven records, #4, was missing the vital signs on the examination form.
One of seven records contained a blank physical examination form signed and dated by the physician.
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Plan of Correction
The errors in completing physical examinations within the required timeframe have been addressed with the doctor. We reviewed the importance of meeting the required timeframe for physical examinations as well as the importance of documenting in the medical chart if the timeframe was unable to be met.
Program Director will oversee the Medical Department at GHWC in cooperation with the Director of Medical Services in order to ensure compliance with physical examinations. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based upon a review of seven client records on June 4 & 5, 2008, the facility failed to provide individualized treatment plans in accordance with the standards.
Two of seven treatment plans reviewed, #3 & 7, were dated prior to the completion of the psychosocial histories and the psychosocial evaluation.
Client record #3 had a treatment plan dated 3/8/08 while the histories and psychosocial evaluation were not completed until 3/10/08.
Client record #7 had a treatment plan dated 12/7/07 while the histories and psychosocial evaluation were not completed until 12/10/08
Four of seven client records reviewed had treatment plans that did not indicate the type and frequency of services, specifically client records #2, 3, 4 & 6 .
Four of seven client records reviewed had treatment plans that did not identify any support services, specifically client records #1, 2, 3 & 6.
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Plan of Correction
Clinical Supervisor has scheduled an in-service training for 7/16/08 with the clinical staff. In the training, the Supervisor will review the proper progression of clinical documentation and the importance of ensuring the individualization of treatment through treatment planning and individual assessment. Supervisor will also stress the importance of including support services in treatment planning.
Clinical Supervisor will review all clinical records and comlpeted documentation on a weekly basis to ensure the treatment planning is individualized and follows the proper progression. |
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 upon a review of seven client records on June 5, 2008, the facility failed to identify how work done by the client at the project was an integral part of their treatment and rehabilitation plan. This was evident in seven of seven client records reviewed.
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Plan of Correction
Clinical Supervisor has scheduled an in-service training for 7/16/08 with the clinical staff. In the training, the Supervisor will review the importance of including work therapy in treatment planning.
Clinical Supervisor will review all treatment plans before signing to ensure that work therapy is reflected throughout the client's duration of treatment. |