INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of personnel records and supervision logs, the project failed to ensure that a counselor assistant with a bachelor ' s degree only counsel clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment.Employee #5 was employed as a counselor assistant on November 23, 2020 and was a current employee at the time of the inspection. Due to employee #5 only having a qualifying Bachelor's Degree, employee #5 was only to counselor clients under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment; however, there was no documentation that the employee received close supervision, which entailed one hour of case review and one hour of direct observation per week.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
Regional Deputy Director conducted a supervision with the Program Director on 6/30/2021 to review the standard for Counselor Assistants to receive one hour of case review and one hour of direct observation per week. With any new Counselor Assistant's onboard moving forward they will receive one hour of case review and one hour of direct supervision per week. This standard will be monitored by the Program Director and Regional Deputy Director through monthly review of Counselor Assistant supervision notes and documentation of direct observation. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
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 on the review of personnel records, the project failed to ensure that employee #4 received a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum withing the regulatory timeframes.Employee #4 was employed as a counselor assistant on March 2, 2020 and was to receive the communicable disease trainings no later than March 2, 2021; however, there was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
There was limited accessibility to the DDAP-approved HIV/AIDS and STD trainings in 2020 and 2021. We are in process of implementing on-site internal HIV/AIDS and STD trainings being offered to staff in our DDAP-licensed programs which will be facilitated by state-approved training facilitators. The Regional Deputy Director conducted a supervision with the Program Director on 6/30/2021 to review requirements for staff training. Employee #4 has been registered for the DDAP-approved HIV/AIDS training and STD training being held in July 2021. This standard will be monitored ongoing by the Program Director through monthly review of staff training records. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on the physical plant inspection, the facility failed to ensure that bunk beds were equipped with securely attached railings on each open side and open end of the bunk.Female room #'s 1 and 3 had bunkbeds that were no equipped with securely attached railings.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Railings were attached to all bunk beds on 6/3/2021. This physical plant standard will be monitored through use of an environmental checklist completed 3 times a day by program staff. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.When tested, the water temperatures in the female bathroom on the first floor was 124 degrees Fahrenheit and in the male bathroom in the basement, it was 122 degrees Fahrenheit.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A thermometer has been purchased to use in monitoring the water temperature throughout the facility. A new hot water pump was ordered on 7/1/2021 and will be installed upon arrival. The water temperature will be monitored through monthly physical plant audits conducted by the Program Director and health and safety inspections conducted six times a year. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
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
Based on the physical plant inspection, the facility failed to keep cold food at or below 40 degrees Fahrenheit, hot food at or above 140 degrees Fahrenheit, and frozen food at or below 0 degrees Fahrenheit.The thermometer in the freezer in the cafeteria read at 35 degrees Fahrenheit.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 6/4/21 the freezer in the cafeteria was repaired. Freezer temperature logs are in place at the facility and freezer temps will continue to be checked daily. In the event a freezer temperature is below or above the standard all items will be removed immediately and placed in an operable freezer, and the freezer manufacturer will be contacted for repair. The Program Director met with the Food Services Manager on 6/4/21 to review this standard. This will be monitored ongoing through monthly physical plant audits conducted by the Program Director and health and safety inspections conducted six times a year. The Quality Assurance Department will conduct quarterly physical audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.Client #1 was admitted on March 15, 2021 and was a current client at the time of the inspection. There was documentation in the client record of communication between facility staff and a recovery home; however, there was no informed and voluntary consent documented in the client records prior to the disclosures.The findings were reviewed with project staff during the licensing inspection.
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Plan of Correction
This individual has since been discharged from the program, and so a consent form can no longer be obtained. In order to ensure that this is not an issue in the future the Program Director held an in-service with staff on 6/7/2021 to review this standard. There will also be a training conducted in July 2021 for all Eastern Region staff on completion of consent forms. This standard will be monitored through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosure is to be made in four of seven client records reviewed.Client #2 was admitted on April 13, 2021 and was a current client at the time of the inspection. A release of information form, signed by the client on April 13, 2021, did not specify the name of the person, agency or organization to whom disclosure is to be made.Client #3 was admitted on April 29, 2021 and was a current client at the time of the inspection. A release of information form, signed by the client on April 29, 2021, did not specify the name of the person, agency or organization to whom disclosure is to be made.Client #4 was admitted on March 25, 2021 and was discharged on May 6, 2021. A release of information form, signed by the client on March 26, 2021, did not specify the name of the person, agency or organization to whom disclosure is to be made.Client #6 was admitted on January 22, 2021 and was discharged on April 6, 2021. A release of information form, signed by the client on January 22, 2021, did not specify the name of the person, agency or organization to whom disclosure is to be made.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
These individuals have since been discharged from the program, and so a consent form can no longer be obtained. In order to ensure that this is not an issue in the future the Program Director held an in-service with staff on 6/7/2021 to review this standard. There will also be a training conducted in July 2021 for all Eastern Region staff on completion of consent forms. This standard will be monitored through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date, event or condition upon which the consent will expire in one of seven client records reviewed.Client #2 was admitted on April 13, 2021 and was a current client at the time of the inspection. A release of information form for a case manager, signed by the client on June 2, 2021, did not document the date, event or condition upon which the consent will expire.The findings were reviewed with project staff during the licensing inspection.
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Plan of Correction
This individual has since been discharged from the program, and so a consent form can no longer be obtained. In order to ensure that this is not an issue in the future the
Program Director held an in-service with staff on 6/7/2021 to review this standard. There will also be a training conducted in July 2021 for all Eastern Region staff on completion of consent forms. This standard will be monitored through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of the patient records, the program failed to verify an individual's identity, including name, address, date of birth, emergency contact and other identifying data in two of four applicable patient records reviewed.Patient #2 was admitted on April 13, 2021 and was a current patient at the time of the inspection. There was no documentation in the patient record that the program verified the patient ' s identity prior to administration of an agent. Patient #3 was admitted on April 29, 2021 and was a current patient at the time of the inspection. There was no documentation in the patient record that the program verified the patient ' s identity prior to administration of an agent. The findings were reviewed with program staff during the licensing process.
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Plan of Correction
On 6/4/2021 documentation was uploaded into client charts # 2 and #3 that verified the client's identity. This standard was reviewed with the Health Services Coordinator on 6/4/2021 and with the Program Director on 6/30/2021. This standard will be monitored ongoing through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of patient records, the program failed to have a narcotic treatment physician document whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least one year prior to admission for maintenance treatment in one of four applicable patient records reviewed. Patient #3 was admitted on April 29, 2021 and was a current patient at the time of the inspection. There was no documentation in the patient record by a narcotic treatment physician that the patient had a current physiological dependency on a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance. The findings were reviewed with program staff during the licensing process.
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Plan of Correction
This standard was reviewed with the program psychiatrist 6/21/2021. The Buprenorphine Physician Review was completed on all clients who are on MAT maintenance. This standard will be monitored ongoing through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on the review of patient records, the program failed to ensure that each female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in two of four applicable patient records.Patient #2 was admitted on April 13, 2021 and was a current patient at the time of the inspection. There was no documentation in the patient record that the patient was notified of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.Patient #6 was admitted on January 22, 2021 and was discharged on April 6, 2021. There was no documentation in the patient record that the patient was notified of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.The findings were reviewed with program staff during the licensing process.
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Plan of Correction
This standard was reviewed with the Health Services Coordinator on 6/4/2021. The consent to treat with Buprenorphine form will be completed during the medical intake for all females. This standard will be monitored ongoing through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
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 the review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.Client #1 was admitted on March 15, 2021 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan completed on March 17, 2021 indicated that the client was to receive one individual counseling session per week; however, there was no documentation of the client receiving any individual counseling sessions for the week of May 2, 2021 through May 8, 2021.Client #5 was admitted on January 8, 2021 and was discharged on April 9, 2021. A comprehensive treatment and rehabilitation plan completed on January 11, 2021 indicated that the client was to receive one individual counseling session per week; however, there was no documentation of the client receiving any individual counseling sessions for the week of January 24, 2021 through January 30, 2021.Client #7 was admitted on February 11, 2021 and was discharged on April 21, 2021. A comprehensive treatment and rehabilitation plan completed on February 26, 2021 indicated that the client was to receive one individual counseling session per week; however, there was no documentation of the client receiving any individual counseling sessions for the weeks of April 4, 2021 through April 10, 2021 and April 11, 2021 through April 17, 2021.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director held an in-service with staff on 6/7/2021 to review this standard. Program Director also held individual supervisions with Counselors to review the requirement for all clients to have a 1:1 individual counseling session every week. This standard will be monitored ongoing through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the project failed to document a complete record on an individual which included case consultation notes in four of seven client records reviewed.Client #4 was admitted on March 25, 2021 and was discharged on May 6, 2021. There were no case consultation notes documented in the client record. Client #5 was admitted on January 8, 2021 and was discharged on April 9, 2021. There were no case consultation notes documented in the client record. Client #6 was admitted on January 22, 2021 and was discharged on April 6, 2021. There were no case consultation notes documented in the client record. Client #7 was admitted on February 11, 2021 and was discharged on April 21, 2021. There were no case consultation notes documented in the client record. The findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director held an in-service with staff on 6/7/2021 to review this standard. Program Director also met with Counselors individually to review the requirement for all clients to have a case consultation every 90 days. This standard will be monitored ongoing through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the project failed to document a complete record on an individual which included an aftercare plan in three of seven client records reviewed.Client #5 was admitted on January 8, 2021 and was discharged on April 9, 2021. There was no aftercare plan documented in the client record. Client #6 was admitted on January 22, 2021 and was discharged on April 6, 2021. There was no aftercare plan documented in the client record. Client #7 was admitted on February 11, 2021 and was discharged on April 21, 2021. There was no aftercare plan documented in the client record. The findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director held an in-service with staff on 6/7/2021 to review this standard. This standard will be monitored ongoing through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
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 the review of client records, the project failed to document a complete record on an individual which included a discharge summary in four of seven client records reviewed.Client #4 was admitted on March 25, 2021 and was discharged on May 6, 2021. There was no discharge summary documented in the client record. Client #5 was admitted on January 8, 2021 and was discharged on April 9, 2021. There was no discharge summary documented in the client record. Client #6 was admitted on January 22, 2021 and was discharged on April 6, 2021. There was no discharge summary documented in the client record. Client #7 was admitted on February 11, 2021 and was discharged on April 21, 2021. There was no discharge summary documented in the client record. The findings were reviewed with project staff during the licensing process.
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Plan of Correction
Program Director held an in-service with staff on 6/7/2021 to review this standard. This standard will be monitored ongoing through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |
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 on the review of client records, the project failed to document a complete record on an individual which included verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan seven of seven client records reviewed.The findings were reviewed with project staff during the licensing process.
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Plan of Correction
The treatment plan has been updated to clearly indicate this aspect of treatment ? therapeutic activities of daily living is now an option available for internal supports in treatment planning. Program Director held an in-service with staff on 6/7/2021 to review this standard. Therapeutic activities of daily living will now be included on all clients' treatment and rehab plans. This standard will be monitored ongoing through bi-monthly chart audits conducted by the Program Director and random monthly chart audits conducted by the Regional Deputy Director. The Quality Assurance Department will conduct quarterly audits, and the Compliance Department will conduct at least annual audits to ensure compliance with this standard. |