INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 14, 2024, 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. Withdrawal, Stabilization and Assessment Center (WSAC) 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of seven personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that three employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor on March 25, 2022, and was still in this position at the time of the inspection. Employee # 6 was due to have the communicable disease trainings no later than March 25, 2023. There was no documentation in the personnel file of the completion of the TB/STD training and the HIV/AIDS training was not completed until May 4, 2023.
Employee # 8 was hired as a support staff on November 3, 2014, and was still in this position at the time of the inspection. Employee # 8 was due to have the communicable disease trainings no later than November 3, 2016. 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.
Employee # 9 was hired as a support staff on March 31, 2010, and was still in this position at the time of the inspection. Employee # 9 was due to have the communicable disease trainings no later than March 31, 2012. 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 facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
The Program Director will review the Training Plans of all current staff members. Any missing trainings will be scheduled as soon as possible based on availability.
The Program Director will ensure that all trainings are completed within required timeframes and according to the annual training plan for each employee. A full review of all trainings will be completed at least monthly to ensure that all staff trainings are up to date, and to ensure that any staff who are nearing the deadline will be scheduled to complete the training prior to the due date.
Additionally, the Program Director will meet quarterly with the Division Director to review training records to ensure that this is attended to. This will be documented in a supervision note.
The Quality Assurance Department will conduct at least semi annual audits to include reviewing the staff trainings that have been completed. If a staff member is missing a training or is coming close to a training deadline, it will be reported to the Program Director during the Audit Review.
|
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that there were not facility heaters that were not permanently mounted or installed in the facility. Specifically, a space heater was discovered in one of the counselor ' s offices.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The heater that was found has been removed.
The Program Director will review DDAP regulations regarding the use of external heating sources during an all staff meeting by 7/1/24.
The Operations Manager will complete their physical plant audit on a weekly basis noting if any space heaters are found. If found it will be removed immediately and the staff member will be informed they are not permitted.
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on two of three applicable client records reviewed, the facility failed to provide documentation of the emergency contact being notified when a client leaves against medical advice in accordance with the facility policy and procedure manual. The facility policy and procedure indicates the emergency contact be notified of the client leaving against medical advice within 12 hours and documented in the client record.
Client # 3 was admitted on April 1, 2024, and was discharged on April 2, 2024. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
Client # 5 was admitted on April 29, 2024, and was discharged on April 30, 2024. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will review the requirements regarding calling the emergency contact upon leaving against facility advice within 12 hours, with all staff during an in-service meeting no later than 7/1/24. This training will include review of the standard workflow and reference the specific form in our EHR. Program Director will monitor all discharges from members who leave against staff advice weekly to ensure emergency contact is called.
In addition, the Program Director will monitor this area during monthly file audits and address discrepancies during staff supervisions.
The Quality Assurance department will monitor this area during semi annual CQI file audits and will report findings to the Program Director
|
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based on a review of the facility policy and procedure manual, the drug storage area and medications shall be inspected by an assigned nurse or designated trained staff member at least quarterly. The Medication and Drug Storage Inspection form shall be completed quarterly by the individual conducting the inspection and by the nurse manager or program director who accompanies him/her during the inspection. The facility was not documenting an inspection at least quarterly of the drug storage area and medications.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director will complete quarterly inspections of the medication area with the nurse on duty and document on The Medication and Drug Storage Inspection form with the first occurring by 7/1/24. This form will be kept in a binder in the medical office.
The Quality Assurance Department will conduct semi-annual audits to include reviewing the binder to ensure the quarterly audits are completed and documented appropriately.
|
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
|
Observations
Based on two of two applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within one week of referral or thirty days after discharge.
Client # 6 was admitted on February 29, 2024, and was discharged on March 3, 2024. There was no follow-up information available in the client record.
Client # 7 was admitted on March 25, 2024, and was discharged on March 26, 2024. There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 20, 2023 and June 14, 2022 annual licensing inspections.
|
Plan of Correction
The Program Director will review the requirements regarding completion of follow-up contact when a client is discharged during an all staff meeting by 7/1/24. This will include completing a follow up contact with the program the client was referred to within 7 days of the appointment or if the client was not referred to another program, within 30 days of discharge. This training will include review of the standard workflow and reference the specific form in our EHR.
In addition, the Program Director will monitor this area during monthly file audits and address discrepancies during staff supervision.
|
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.
|
Observations
Based on four of six applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur within fifteen days.
Client # 8 was admitted on April 10, 2024, and was still active at the time of the inspection. A case consultation was due to occur no later than April 25, 2024. There was no case consultation documented in the client record.
Client # 11 was admitted on April 20, 2024, and was still active at the time of the inspection. A case consultation was due to occur no later than May 5, 2024. There was no case consultation documented in the client record.
Client # 12 was admitted on January 18, 2024, and was discharged on February 14, 2024. A case consultation was due to occur no later than February 2, 2024. There was no case consultation documented in the client record.
Client # 14 was admitted on February 16, 2024, and was discharged on March 29, 2024. A case consultation was due to occur no later than March 2, 2024. There was no case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
The Program Director will review the requirements regarding case consults with all staff during staff in-service no later than 7/1/24. Case consults will be reviewed weekly during clinical team meeting. Program Director will follow up weekly during chart audit.
The Quality Assurance Department will conduct semi-annual audits to include reviewing documentation of follow up contacts as appropriate
|
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.
|
Observations
Based on one of two applicable client records reviewed, the facility failed to provide an aftercare plan upon completion of treatment in client record # 12.
Client # 12 was admitted on January 8, 2024 and was discharged on February 14, 2024. There was no aftercare plan available in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
The Program Director will review the requirements regarding Aftercare Planning with all staff during staff in-service no later than 7/1/24. This training will include a review of the standard workflow and reference the specific form in our EHR.
In addition, the Program Director will monitor this area during monthly file audits and address discrepancies during staff supervision.
The QA department will monitor this area during quarterly CQI file audits and will report findings to the Program Director.
|
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of administrative information, client records, and personnel records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for follow up information were submitted and approved by the Department for the June 20, 2023, and June 14, 2022, licensing inspections. Follow up information was again found to be a deficiency in the May 14, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction:
The Program Director will be responsible for the implementation and compliance of all plans of correction. The Program Director will collect data from past inspections to determine how to avoid repeated citations and the best procedures for implementing a new POC. It will be the responsibility of the Program Director and the Division to ensure that future violations are not incurred in this area and that POC's are put in place. The Division Director will also ensure POC are followed by meeting with Program Director to audit past and present POC procedures. The Quality Assurance Team will audit the program semi annually to make sure that the program remains in compliance. All data gathered from the monthly and semiannual audits will be recorded. These methods will focus on the proper protocol for completing all relevant documentation.
|