INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13, 2006 through March 14, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on April 6, 2006.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The third shift was consistently without first aid and CPR coverage by program personnel. The second shift was also without first aid and CPR coverage on occasion.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
No training hours were documented as having been earned for employee number 5 from when the program opened in August 2005 to when the training year ended in December 2005.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
The client to counselor ratio was twelve to one.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
One of the two refrigerators and freezers did not have a thermometer and therefore a temperature reading could not be obtained.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
While there is a fire suppression unit installed in the hood over the stove/oven in the kitchen, there were no portable fire extinguishers found in the kitchen area.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
No fire drills conducted in December 2005.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Approximately half of the fire drills conducted since the program opened did not include the exit(s) used during the drills.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
There was no documentation to show that either a fire alarm or smoke detector was set off in order to perform the fire drills.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
A letter of agreement for 24 hour emergency medical and psychiatric coverage was not provided.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
The consents to release information to CBH were missing for all CBH funded clients in clinical records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
The PCPC used to authorize treatment with CBH contained the names and doses of the medication(s) that the clients were currently taking while in treatment in all clinical records reviewed. This exceeded that allowed by 4 Pa. Code 255.5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
The monthly inspections of the medication area, as per the program's policies and procedures, have not been conducted since the program opened.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Program staff personnel are not consistently including their initials in the medication records after a client takes their required medications, as per the program's policies and procedures.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
In four of four clinical records reviewed, numbers 1, 2, 3, and 4, the client histories being received from the referring treatment programs do not have any documentation to verify that the information was reviewed with the client by their new counselor and that any changes or updates, as needed, have been made.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
Physical examinations were missing in two of four clinical records reviewed, numbers 3 and 4. Examinations were incomplete in two of four clinical records reviewed, numbers 1 and 2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Four of four clinical records had psychosocial evaluations that were completed by the counselor two to three months after the date of admission, contrary to the program's policy of completing the evaluations within five days of admission.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Missing in three of four clinical records, numbers 1, 2, and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
Comprehensive treatment plans were late in two of four clinical records numbers 1 and 4. The program's policy states that the treatment plans are to be completed no later than five days from the date of admission.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Four of four clinical records, numbers 1, 2, 3, and 4 were missing the type and frequency of treatment services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The treatment plan updates do not consistently indicate why a goal that was identified as "achieved" by the counselor was continuing to be addressed in each subsequent update.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.51(e)(5) LICENSURE Educational support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
No verification currently in writing that supports the agreement between Gaudenzia Washington House and the Community College of Philadelphia to offer educational supportive services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
Missing in three of four clinical records, numbers 1, 3, and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
Missing in two of four clinical records, numbers 4 and 6.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |