INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 19, 2019 of Gaudeniza, Inc. by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudeniza, Inc 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the policy and procedure manual, the facility failed to follow their policy in regard to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated, "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16th, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
While an overall Project Training Plan was not completed until 5-16-19, the Division Director of Ambulatory Services which oversees the Coatesville site, did complete an overall Training Plan for all of her staff at in the Ambulatory Division. This training plan was presented to the Licensing Specialist during her licensing visit on June 19, 2019.
Going forward, the Program Director will ensure the Project wide training plan is requested to be completed prior to the end of January each year. |
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 chart review of personnel records, employee # 3 and # 4 did not receive their individual training plan until June 18, 2019. The facility's training year runs from January 2019-December 31, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will work with the Clinical Supervisor to ensure that all staff have a current and valid training plan that coincides with both their hire date and the facility training plan policy.
The Facility director met with the Clinical Supervisor 8/12/19 to review the Training Plan requirements for all staff.
The Facility Director will monitor staff files prior to December 31 to ensure the training plans for all staff are completed according to policy. |
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 files, employee #1, #2 and #7 were not trained in the use of the fire extinguisher upon employment.
Employee #1 was hired on March 13, 2019 and was still employed at the time of the inspection. Documentation in employee #1 s personnel file indicated that the employee had not received the required training at the time of the inspection
Employee #2 was hired July 10, 2018 and was still employed at the time of the inspection. Documentation in the employees personnel file indicated that the employed did not receive the required training until June 18, 2019.
Employee #7 was hired on January 7, 2019 and was still employed at the time of the inspection. Documentation in the employee's personnel filed indicated that the employee did not receive the required training until June 18th, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has ensured that all staff onsite have received fire extinguisher training to date.
Going forward, the Facility Director will ensure all staff will receive the fire extinguisher training on their first day at the facility, and documenting this training in the binder kept for fire safety and training.
In addition, all staff training certificates will be submitted to the HR Dept at Corporate, so if the survey is conducted at the Corporate level, the information will be there for review.
The Facility director will review personnel files quarterly to ensure all required information is up to date.
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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 files, employee #1, #2 and #7 was not trained to perform assigned tasks during emergencies.
Employee #1 was hired on March 13, 2019 and was still employed at the time of the inspection. Documentation in employee #1's personnel file indicated that the employee had not received the required training at the time of the inspection
Employee #2 was hired July 10, 2018 and was still employed at the time of the inspection. Documentation in the employees personnel file indicated that the employed did not receive the required training until June 18, 2019.
Employee #7 was hired on January 7, 2019 and was still employed at the time of the inspection. Documentation in the employee's personnel filed indicated that the employee did not receive the required training until June 18th, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will ensure all new staff will receive the required training to perform assigned tasks during emergencies within the first 2 days of employment by showing the training video and having them complete the post test. A certificate of completion will then be sent to Corporate and a copy in the personnel file onsite.
The Facility Director will review personnel files quarterly to ensure all documentation is completed and available as required.
Ongoing.
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
During a physical plant inspection on June 19, 2019 the facility failed to ensure that counseling sessions couldn ' t be seen or heard outside the counseling room. During the inspection room 8 had a counseling session in process with the door open.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Despite all counselors having been trained in confidentiality regulations and having sound machines to mute counseling sessions, a counselor did in fact have his door open during a counseling session.
This was addressed as a training with all staff the following week during staff meeting.
The counseling rooms are monitored daily for compliance by the clinical supervisor.
The Facility Director will monitor the counseling offices daily to ensure no sessions are held with the doors open and the noise machines off. If this is found to happen again, there will be a reprimand according to program policy. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 3, 4, and 7.
Client #1 was admitted on April 10, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on April 5th, 2019 for the funding source that allowed for the release of Client info/profile, client screen, TAPS(initial/follow up) ASAM/PCPC, Recovery plan, TB screen and gambling screen.
Client #3 was admitted on March 27, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on March 20th, 2019 for the funding source that allowed for the release of Client info/profile, client screen, TAPS(initial/follow up) ASAM/PCPC, Recovery plan, TB screen and gambling screen.
Client #4 was admitted on April 10, 2019 and was an active client as of the date of the inspection. A consent to release form was signed and dated on March 15, 2019 for the funding source that allowed for the release of Client info/profile, client screen, TAPS(initial/follow up) ASAM/PCPC, Recovery plan, TB screen and gambling screen.
Client #7 was admitted on September 6, 2018 and was discharged on March 6, 2019 inspection. A consent to release form was signed and dated on November 9, 2018 for the funding source that allowed for the release of Client info/profile, client screen, TAPS(initial/follow up) ASAM/PCPC, Recovery plan, TB screen and gambling screen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All WITS consents previously required by the SCA, are removed from all intake packets.
All staff will be trained on 8-27, 2019 in regards to not using this consent in any form.
Clinical Supervisor will review 30% of all client records to ensure this consent is not being utilized.
Facility Director will monitor to ensure compliance ongoing. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of seven client records, the facility's client rights documentation, included in the orientation packet, failed to include all the required client rights. The facility failed to include that:
Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
Clients have the right to appeal a decision limiting access to their records to the director.
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director updated the Client Bill of Rights to expand on what was already there under # 3. The Client Bill of Rights now includes the proper verbiage to include all that is stated in 709.30 (3). A client has the right to inspect his/her own records. the program director may remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing any information shall be documented and kept on file.
The Program Director reviewed the new form with all staff prior to implementing the new form. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
The facility failed to develop a data collection and record keeping system that allows for efficient retrieval of data needed to measure the project ' s performance. Client #6 ' s record was unable to be located at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has undergone an almost total changeover in both staff and client records to electronic health records for all clients.
As of July 31, 2019, all client files were processed by the new administrative coordinator and placed in an appropriate organizational system.
As of 8-6-19, a specific filing system was implemented with all staff being educated on the procedures in an effort to ensure the whereabouts of all files are known at all times.
The Facility Director will randomly search for client files weekly to ensure that all client files are able to be located at all times according to storage policies and regulations.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one applicable record reviewed.
Client #7 was admitted on September 6, 2018 and was administratively discharged on March 6, 2019. There was no documentation in writing of a decision to involuntarily terminate the client's treatment at the project.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will provide a staff training to review the procedures for involuntarily discharging a client.
The Facility Director will develop a written involuntary termination letter with a space for the reason for the discharge and include a statement that an opportunity for reconsideration is available to them.
This form will be reviewed with staff at the training on this procedure.
The clinical supervisor will monitor all potential discharges in team meeting weekly to ensure this letter is utilized as appropriate.
The Clinical Supervisor will review 25% of all monthly discharges to ensure this letter is a part of the discharge process. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 on a review of seven client records, the facility failed to document comprehensive individual treatment and rehabilitation plans in three client records.
Client #4 was admitted on April 10, 2019 and was still active at the time of inspection. The client ' s preliminary treatment plan was created on May 9, 2019. At the time of the inspection the client did not have a compressive individual treatment and rehabilitation plan.
Client #5 was admitted on July 26, 2019 and was discharged on January 24, 2019. The client ' s preliminary treatment plan was created on July 26, 2019. At the time of the inspection the client did not have a compressive individual treatment and rehabilitation plan.
Client #6 was admitted on August 22, 2018 and was discharged on January 1, 2019. The client ' s preliminary treatment plan was created on August 22, 2018. At the time of the inspection the client did not have a compressive individual treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(How) A staff training was held for the clinical staff on 7/22/19 to review how to access the various treatment plans in the EHR and the time frames for each. This is the initial treatment plan, the comprehensive treatment plan as well as the time frames for updated treatment plans.
(What) The clinical supervisor will review 3 random client files weekly for three months to ensure treatment plans are being completed timely.
(Time frame) Ongoing for the next year.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in three client records reviewed.
Client # 5 was admitted on July 26th, 2018 and was discharged on January 24, 2019. A treatment and rehabilitation plan update was completed on July 26, 2018 and the next update was due no later than September 26, 2018; however, there was no update documented in the record at the time of the inspection.
Client # 6 was admitted on August 22nd, 2018 and was discharged on January 1, 2019. A treatment and rehabilitation plan update was completed on August 22, 2018 and the next update was due no later than October 22, 2018; however, there was no update documented in the record at the time of the inspection.
Client # 7 was admitted on September 6, 2018 and was discharged on March 6, 2018. A treatment and rehabilitation plan update was completed on September 20, 2018 and the next update was due no later than November 20, 2018 ; however, there was no update documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(How) A staff training was held for the clinical staff on 7/22/19 to review how to access the various treatment plans in the EHR and the time frames for each. This included the time frames for updated treatment plans.
(What) The clinical supervisor will review 3 random client files weekly for three months to ensure treatment plans are being completed timely, and monthly thereafter.
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709.93(a)(1) 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:
(1) Consent forms.
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Observations
Based on a review of client records, the project failed to provide a complete client record for client #'s 5, 6, and 7.
Client #5 was admitted July 26, 2018 and was discharged on January 24, 2019. The client record did not contain documentation of follow up information.
Client #6 was admitted August 12, 2018 and was discharged on January 1, 2019. The client record did not contain documentation of a discharge summary, aftercare plan, case consultations and follow up information.
Client #7 was admitted September 6, 2018 and was discharged March 6, 2019. The client record did not contain documentation of case consultation and follow up information.
These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility staff failed to provide a complete record for client's # 5, 6 and 7.
(How) A staff training was held to review what constitutes a complete client record during a staff meeting following the inspection.
(What) The clinical supervisor has implemented a chart review to ensure clinical documentation is completed in a timely manner. (When) Random chart reviews are completed weekly. Peer reviews will be implemented by 8-15-19 to add to the monitoring for compliance.
Also, all documentation is now being completed in our EHR, so it is easier to monitor for compliance by the clinical supervisor and Facility Director. |