INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27 through 29, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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 October 24, 2007.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of policies and personnel records on August 8 - 14 and August 27, 2007, the facility failed to complete individual training plans according to the policy. Individual training plans were late for employees #4, 6 and 9.
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Plan of Correction
The individual training plan will be developed by the employees' supervisor (clinical staff is program supervisor & administrative staff is administrative cooridnator). Individual training plans will be completed by the aforementioned staff every December at the time of the performance evaluation for the next year. The process will be monitored by the administrative coordinator in administrative meetings. |
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 on a review of personnel records, the facility failed to ensure that all staff received training on the use of fire extinguishers within the required time frame. Employee #9 received training 13 days after being hired.
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Plan of Correction
Employees will be required to sign their New Employee Orienation Training Checklist at the end of the first week of hire which includes the use of the fire extinguisher. To be implemented by the program supervisor and monitored by the administrative coordinator. |
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 on a review of personnel records, the facility failed to ensure that all staff received training for emergencies within the required time frame. Employee #5 received training 43 days after being hired and employee #9 received training 13 days after being hired.
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Plan of Correction
Employees will be required to sign their New Hire Orientation Training Checklist at the end of the first week of hire which includes the use of the fire extinguisher. To be implemented by the program supervisor and monitored by the administrative coordinator. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on a review of the 2005-2006 annual report, the facility failed to identify activities and accomplishments of the preceding year for the program.
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Plan of Correction
The annual report for the FY '07 will be printed and available for the current FY and every year thereafter and will include activities and accomplishments for the previous FY. Person Responsible - Director of Development. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of the goals and objectives for the 2007-2008 fiscal year, the facility failed to identify available resources and time frames.
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Plan of Correction
Executive staff who are responsible for specific goal areas will develop and revise plans in specific goal areas in consultation with their respective Board Committees and available resources for approval at the September board meeting and every September thereafter. Person Responsible - Executive Staff |
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 on a review of client records on August 28, 2007, the facility failed to obtain an informed and voluntary consent to release information, identify the specific information to be disclosed and adhere to what is allowable under 4 Pa. Code in eight of eight records.
The Findings were:
Client record # 1 contained consents to release information to Accelerated Rehabilitation Disposition (ARD), Cumberland Perry Drug and Alcohol Commission and the Department of Public Welfare that identified the information to be released as "Recommendations" without defining the recommendations.
Client record #2 contained consents to release information to Quest and Pinnacle Health that identified the information to be released as "Recommendations" without defining the recommendations.
Client record #3 contained consents to release information to Children and Youth, Cumberland Perry Drug and Alcohol Commission and the funding source that identified the information to be released as "Recommendations" without defining the recommendations.
Client record #3 contained a consent to release information to Children and Youth that allowed for the release of treatment plan goals.
Client record #4 contained consents to release information to health insurance companies that identified the information to be released as "Recommendations" without defining the recommendations.
Client record #5 contained a consent to release information to York Adams Drug and Alcohol that allowed for the release of treatment plans.
Client record #6 contained a consent to release information to the School District that identified the information to be released as "Recommendations" without defining the recommendations.
Client record #6 contained consents to release information to the Cumberland Perry Office of D & A Commission and to Blue Cross that did not inform the client of their right to revoke a consent verbally.
Client record #7 contained consents to release information to health insurance companies, the funding source and York County Adult Probation that identified the information to be released as "Recommendations" without defining the recommendations.
Client record #7 contained a consent to release information to the funding source that allowed for the release of treatment plans.
Client record #8 contained consents to release information to the Cumberland County ARD Program and CBHNP that identified the information to be released as "Recommendations" without defining the recommendations.
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Plan of Correction
The program supervisor will provide a training on Consents to Release Information:
1. Recommendations for level of care
2. Five areas which can be released to county and insurances resources
3. The importance of client's right to revoke consents.
The consents will be monitored through the QI process monthly to demonstrate the training implementation. |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based on a review of client records on August 28, 2007, the facility failed to document medication records in four of eight records, #1, 2, 3 and 8.
The findings were:
Client record #1 had no entries for medications listing dose and frequency even though the client indicated in their medical history that they were taking medications for medical problems at that time.
Client record #2 contained a bio-psychosocial form which lacked any section to address the client's medical history and medications.
Client record #3 contained a physical indicating that the client was on Prozac, Thorazine and Benadryl. The clinical assessment listed these three medications and also listed Lexapro, however neither the physical nor the assessment listed the dose and frequency of the medications.
Client record #8 contained an assessment where the section regarding medications was left blank and there was no notation to indicate if it was not applicable.
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Plan of Correction
Program Supervisor will train clinical personnel as to the appropriate information collection regarding medication:
1. Type
2. Dosage
3. Frequency
4. Medical Problem
5. Applicability of information when none is taken
This training will be reviewed in the QI process monthly for implementation. |