INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2014 to January 24, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Broad Street 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on an interview with the facility director, the facility failed to ensure that clinical supervisors participate in documented monthly meetings with their supervisors to discuss their duties and performance in that position in one of one personnel record reviewed.
The findings include:
The facility was required to ensure that the clinical supervisor participate in documented monthly meetings with his supervisor to discuss his duties and performance for employment in that position. Employee # 3 is the clinical supervisor and was hired February 18, 2013. The Licensing Specialist asked to see documentation of employee # 3 participating in monthly meetings with his supervisor to discuss his duties and performance. Documentation of employee # 3 participating in monthly meetings with his supervisor to discuss his duties and performance was not presented for review.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 1:30 P.M.
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Plan of Correction
The Program Director has implemented a binder system containing a section for all staff. During each supervision, a supervison form will be filled out, dated, and signed by the supervisor and the supervisee. The supervisons will consist of discussing job performance, discussion of duties, etc. The form will be copied, with the orginal being placed in the binder and the copy being placed in the personal file of the supervisee. This will ensure that the form is available in two locations for review. The supervisons will occurr on a monthly basis, unless otherwise specified. This plan will be effective as of 2/14/14
The new supervision procedure will include documented monthly meetings of employee # 3 with the facility director and that the documented meetings will include a discussing of his duties and performance in his position as a clinical supervisor. |
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 personnel records, the facility failed to document an individual training plan annually for each employee in two of eight personnel records reviewed.
The findings include:
From January 23, 2014 to January 24, 2014, eight personnel records requiring documentation of an individual training plan were reviewed. The facility failed to document an individual training plan in two of eight personnel records reviewed, specifically, personnel records # 6 and 8.
Employee # 6 is a counselor and was hired on October 22, 2012. The individual training plan for employee # 6 was due December 31, 2013. However, personnel record # 6 did not include documentation of an individual training plan as of January 24, 2014.
Employee # 8 is an intake specialist and was hired on February 7, 2005. The individual training plan for employee # 8 was due December 31, 2013. However, personnel record # 8 did not include documentation of an individual training plan as of January 24, 2014.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 1:30 P.M.
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Plan of Correction
The training plans for employees #6 and #8 that were due on December 31, 2013 will be completed by February 26, 2014. Both of the individual training plans will be completed by the Program Director and the employees.
Moving forward, the Program Director and the Program Supervisor will ensure to have all of the individual training plans completed by December 31st of each year. A copy of each indiviual training plan will be placed in the staff person's individual personnal file at the corporate office and within the facility. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed 12 clock hours of required training in one of one personnel record reviewed.
The findings include:
From January 23, 2014 to January 24, 2014, one personnel record requiring documentation of 12 clock hours of training was reviewed. The facility failed to provide documentation of 12 clock hours of training in one of one personnel record reviewed, specifically, personnel record # 3.
Employee # 3 is a clinical supervisor and was hired for his current position at the facility on February 18, 2013 but has been a clinical supervisor with the project for over ten years. Employee # 3 was required to complete 12 clock hours of annual training hours by December 31, 2013. However, personnel record # 3 only had documentation of 6 clock hours of annual training for the January 1, 2013 to December 31, 2013 training year as of January 24, 2014.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 10:00 A.M.
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Plan of Correction
Moving forward, the clinical supervisor is currently enrolled in trainings for this upcoming year, that calculate to 12 clock hours. Moving forward, the Program Director will ensure to enroll the supervisor (and all other staff) immediately into trainings per the development of the individual training plan. Program Director will also ensure to obtain a copy of the attendance of the training and ensure that it is filed in the personnal record at the corporate office and at the Broad Street site, which will ensure that a copy is always available for review.
Program Director will make sure that employee # 3 and any other clinical supervisor completes at least 12 clock hours of training for this upcoming year and every year thereafter. |
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 a physical plant inspection and an interview with the cook, the facility failed to ensure that hot food was served at or above 140 F.
The findings include:
A physical plant inspection was conducted on January 24, 2014. The Licensing Specialist asked to see a food serving temperature log during the inspection. A food serving temperature log was not presented for review; therefore, the facility lacked documentation to verify that hot food at the facility had been served at or above 140 F.
The findings were confirmed during an interview with the cook on January 24, 2014 at approximately 2:30 P.M.
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Plan of Correction
The food serving temperature logs was formulated after the inspection on January 24, 2014. The log indicates the week, day, entree, starch, vegatable, slad, dessert and beverage. Each log sheet is kept in a binder, located in the kitchen for use during each meal. The cook started using the logs on February 22, 2014 and the facility began to immediately serve hot food at a temperature of 140F.
Moving forward, the logs will be used daily by the cook and checked daily by the Program Supervisor. If the Program Supervisor is unavilable, the Program Director will ensure to check the logs. Both the Program Supervisor and the Program Director will do periodic checks of the actual hot food temperature. Also note that the Program Supervisor and the Program Director will ensure that the hot food is served at a temperature of 140 or above on a regular basis. |
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 review.
The findings include:
From January 23, 2014 to January 24, 2014, one personnel record requiring documentation of fire extinguisher training was reviewed. The facility did not provide documentation that they instruct staff in the use of the fire extinguisher upon staff employment in one of one personnel record reviewed, specifically, personnel record # 5.
Employee # 5 is a counselor and was hired November 19, 2013. Employee # 5 was due to complete fire extinguisher training upon employment. However, Employee # 5 did not complete fire extinguisher training until December 20, 2013.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 10:00 A.M.
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Plan of Correction
All employees will complete their fire extinguisher and building specific fire safety training within 48 hours of employment at the facility. The training will be conducted by the Program Supervisor. In the absence of the Program Supervisor, the Program Director will conduct the training. Each staff member receiving the training will (1.)see a film, (2.)learn where all of the fire extinguishers are located as well as all of the fire exits within the building and (3.)obtain instruction on how to properly operate a fire extringuisher. Each new staff member will also be given a questionarre pertaining to the training. After the completing of the training each new staff member will receive a certificate, noting successful completion of the use of the fire extinguishers, and general fire safety within the building. |
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 upon employment to perform assigned tasks during emergencies in two of two personnel records reviewed.
The findings include:
From January 23, 2014 to January 24, 2014, two personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility failed to ensure that employees completed emergency training upon employment in two of two personnel records reviewed, specifically, employees # 3 and 5.
Employee # 3 is a clinical supervisor and was hired on February 18, 2013. Employee # 3 was due to complete emergency training by February 18, 2013; however, personnel record # 3 did not include documentation of emergency training as of January 24, 2014.
Employee # 5 is a counselor and was hired on November 19, 2013. Employee # 5 was due to complete emergency training by November 19, 2013; however, employee # 5 did not complete emergency training until December 20, 2013.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 10:00 A.M.
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Plan of Correction
Employee #3 emergency training has been completed as of 2/24/14. The training was conducted by Program Director. As stated employee #5 completed her training Deceober 20, 2014 which is not within the time frame that it should be completed in.
Moving forward, all new employees will receive the emergency training (which is specific to the facility) within 48 hours of employment at the site. The training will be conducted by the Program Supervisor. In the absence of the Program Supervisor, the Program Director will conduct the training. Upon completion of the training, the employee will receive a certificate noting completing of the training, as well as completing an evaluation form. A copy of all documentation of the completed emergency training will be placed in the employee's personnal file. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on an interview with the facility director, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the fiscal year.
The findings include:
The administrative documentation was reviewed on January 23, 2014 and January 24, 2014. The facility was required to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of their fiscal year. The facility's 2012 through 2013 fiscal year ended on June 30, 2013. The Licensing Specialist asked to see a copy of the facility's financial audit for their fiscal year that ended on June 30, 2013. A copy of the facility's financial audit for their fiscal year that ended on June 30, 2013 was not presented for review.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 1:30 P.M.
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Plan of Correction
1) The facility's financial audit for the fiscal year that ended on June 30, 2013 will be completed March 31, 2013.
2) Moving forward the Controller at the Corporate office will ensure that the financial audit report is completed and submitted on a timely basis. The Controller's office staff will ensure that each region receives a copy of the completed audit.
3)The Controller's office has discussed this issue with the CFO, and procedures have been put in place to make sure that the audit is completed timely moving forward.
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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, the facility failed to document 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 made and the specific information disclosed in three of ten client records reviewed.
From January 23, 2014 to January 24, 2014, ten client records requiring documentation of an informed and voluntary consent for the disclosure of information were reviewed. The facility did not document 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 made and the specific information disclosed in three of ten records reviewed, specifically, client records # 4, 5, and 6.
Client record # 4 contained two consents to release information dated 11/14/13; however, the consent to release information did not include the name of the person, agency or organization to whom disclosure is made and the specific information disclosed.
Client record # 5 contained three consents to release information dated 11/13/13; however, the consent to release information did not include the name of the person, agency or organization to whom disclosure is made and the specific information disclosed.
Client record # 6 contained two consents to release information dated 11/26/13; however, the consent to release information did not include the name of the person, agency or organization to whom disclosure is made and the specific information disclosed.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 3:00 P.M.
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Plan of Correction
The two consents to release information that were located in chart #4 that were dated 11/14/13, and were not filled out in their entirety were removed from said chart on 1/24/14 and shredded. The three consents to release information statemtns that were located in chart #5 dated 11/13/13, and were not filled out in their entirety were removed from said chart on 1/24/14 and shredded. The two consents to release information statements that were located in chart #6 that were dated on 11/26/14 were removed from the chart on 1/24/14 and shredded.
The consent to release information for the above stated chatts will be completed filled out in their entirety) by the clients and the staff and placed back in said charts by 2/26/14.
Moving forward, the administrator will ensure to fill out all initial consents in their entirety upon admission. The consent will then be given to the Program Supervisor for review for completeness prior to being placed in the residents chart. The counselor will ensure to complete follow-up consents (as needed) in their entirety and present to the Program Supervisor to ensure completeness prior to being placed in the chart.
The Program Supervisor and the Program Director will audit the charts on a bi-monthly basis to ensure that all consents for disclosure are up to date and filled out in their completeness. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan in seven of nine client records reviewed.
The findings include:
From January 23, 2014 to January 24, 2014, nine client records requiring documentation of short-term and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in seven of nine records reviewed, specifically, client records # 1, 2, 4, 5, 8, 9, and 10.
Client # 1 was admitted July 2, 2013. The individual treatment and rehabilitation plan was completed on July 9, 2013, but it did not include documentation of the long-term goals for treatment as of January 24, 2014.
Client # 2 was admitted July 8, 2013. The individual treatment and rehabilitation plan was completed on July 12, 2013, but it did not include documentation of the long-term goals for treatment as of January 24, 2014.
Client # 4 was admitted November 8, 2013. The individual treatment and rehabilitation plan was completed on November 12, 2013, but it did not include documentation of the long-term goals for treatment as of January 24, 2014.
Client # 5 was admitted November 15, 2013. The individual treatment and rehabilitation plan was completed on November 15, 2013, but it did not include documentation of the long-term goals for treatment as of January 24, 2014.
Client # 8 was admitted August 9, 2013 and discharged October 21, 2013. The individual treatment and rehabilitation plan was completed on August 12, 2013, but it did not include documentation of the long-term goals for treatment as of January 24, 2014.
Client # 9 was admitted April 11, 2013 and discharged July 23, 2013. The individual treatment and rehabilitation plan was completed on June 5, 2013, but it did not include documentation of the long-term goals for treatment as of January 24, 2014.
Client # 10 was admitted August 2, 2013 and discharged November 1, 2013. The individual treatment and rehabilitation plan was completed on August 6, 2013, but it did not include documentation of the long-term goals for treatment as of January 24, 2014.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 3:00 P.M.
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Plan of Correction
The individual treatment plan for client record #1 dated July 9, 2013, will be revised to include a long term goal. The date of completion will be completed by 3/10/14. The revised treatment plan will be reviewed by the Program Supervisor and Lead Counselor for accuracy and completeness. The revised treatment plan, will then be placed with the plan that it is replacing. The revised plan will have the word revised the front of the page to deplict which plan it is replacing. All parties will sign off on the completed revised plan.
The individual treatment plan for client record #2 dated July 12, 2013, will be revised to include a long term goal. The date of completion will be completed by 3/10/14. The revised treatment plan will be reviewed by the Program Supervisor and Lead Counselor for accuracy and completeness. The revised treatment plan, will then be placed with the plan that it is replacing. The revised plan will have the word revised the front of the page to deplict which plan it is replacing. All parties will sign off on the completed revised plan.
The individual treatment plan for client record #4 dated NOvember 12, 2013, will be revised to include a long term goal. The date of completion will be completed by 3/10/14. The revised treatment plan will be reviewed by the Program Supervisor and Lead Counselor for accuracy and completeness. The revised treatment plan, will then be placed with the plan that it is replacing. The revised plan will have the word revised the front of the page to deplict which plan it is replacing. All parties will sign off on the completed revised plan.
The individual treatment plan for client record #5 dated November 15, 2013, will be revised to include a long term goal. The date of completion will be completed by 3/10/14. The revised treatment plan will be reviewed by the Program Supervisor and Lead Counselor for accuracy and completeness. The revised treatment plan, will then be placed with the plan that it is replacing. The revised plan will have the word revised the front of the page to deplict which plan it is replacing. All parties will sign off on the completed revised plan.
The individual treatment plan for client record #8 dated July 9, 2013, will be revised to include a long term goal. The date of completion will be completed by 3/10/14. The revised treatment plan will be reviewed by the Program Supervisor and Lead Counselor for accuracy and completeness. The revised treatment plan, will then be placed with the plan that it is replacing. The revised plan will have the word revised the front of the page to deplict which plan it is replacing. All parties will sign off on the completed revised plan.
Moving forward, the counselors will bring their completed treatment plans to the Program Supervisor and Lead Counselor for review and completeness three days prior to the treatment plan meeting. The treatment plans will be reviewed to ensure that long term and short term goals are present and measurable on each of the treatment plans that are presented. If a long or short term goal is missing from the plan, the plan will be given back to the counselor for correction prior to submission at the treatment team meeting. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project regarding documentation of follow-up information in two of three client records reviewed.
The findings include:
From January 23, 2014 to January 24, 2014, four client records requiring documentation of follow-up information were reviewed. The facility did not document follow-up information in two of three records reviewed, specifically, client records # 9 and 10.
Client # 9 was admitted April 11, 2013 and discharged July 23, 2013. The follow-up information was due July 30, 2013. However, client record # 9 did not include documentation of follow-up information as of January 24, 2014.
Client # 10 was admitted August 2, 2013 and discharged November 1, 2013. The follow-up information was due December 1, 2013. However, client record # 10 did not include documentation of follow-up information as of January 24, 2014.
The findings were confirmed during an interview with the facility director on January 24, 2014 at approximately 3:00 P.M.
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Plan of Correction
Follow-up information for client records #9 and #10 will be completed by target date 3/3/14. Moving forward, the counselor for the indivuals that have been discharged will make a follow-up phone call to the individuals that have been discharged 5 days after the discharge date. The phone call will include gathering information regarding the client's current status, seeing if the client has kept all appointments that were set (psychiatric, outpatient), checking to see if the client is maintaining stable housing, and if the client is attending aftercare. All gathered information will be documented on an individual session form, which will state "discharge follow-up information" The Program Supervisor will audit all discharge charts and will be responsible for ensuring that a follow-up discharge note is completed within 5 days of discharge.
If the client is not available during the follow-up phone call, the counselor will document as such and will make a second attempt to obtain follow-up information. This second attempt will also be documented as stated above.
The Program Director will audit all discharge charts at the end of the month to ensure completeness which includes the follow-up discharge documentatiion. |