INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29, 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 Washington House 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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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 on April 29, 2024, the facility failed to keep frozen food at or below 0 degrees Fahrenheit, as the freezer in the kitchen was 13 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new freezer has been ordered. It is expected to be delivered by 6/17/2024.
In the meantime, staff are ensuring that the door on the current freezer remains closed and sealed tightly to maintain temperature. All food that had been above
freezing has been disposed of.
The temperature log will be maintained on a daily basis.
Program Director will be responsible for ensuring that POC is implemented. |
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
Based on a review of the fire drill logs from July 2023 through March 2024, the facility failed to set off a fire alarm or smoke detector at any of the fire drills conducted during the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program staff conducting the drill will communicate and coordinate with the other program co-located in the same facility to ensure that the alarm is sounded for every drill.
The Program Director will oversee this process and review all documentation afterwards to ensure that all requirements are met and all documentation is complete. |
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.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client # 3 was admitted on December 14, 2023 and was discharged Against Staff Advice (ASA) on February 18, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
This is a repeat citation from the May 26, 2022 and June 12, 2023 annual licensing renewal inspections.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
It is the responsibility of the primary counselor to notify the Emergency Contact person within 12 hours when a member leaves the program ASA. If the primary counselor is not present, the Recovery Support Professional will be responsible for notifying the Emergency Contact. In all cases, an Emergency Contact follow-up note will be completed in the client's chart. The Program Director will communicate with the counselor following any ASA discharge to ensure that they have made this contact.
The Program Director will review the policy with all staff in an in-service training no later than 6/10/24. The Program Director will complete a weekly Detail of Discharges by program to ensure that if a member does leave ASA that the follow-up contact note has been completed.
The Program Director will complete at least monthly audits of a sample of charts. Any issues noted will be brought to the attention of the clinician and corrected immediately.
The Quality Assurance department will conduct at least semi-annual audits, the results of which will be brought to the immediate attention of the Program Director to be addressed as described above. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility's policy and procedure manual in three out of three applicable personnel records reviewed. The facility's policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 1 each year.
Employee # 1 was hired as the Project Director on September 9, 2019 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 28, 2024.
Employee # 2 has been in the position of Facility Director since July 19, 2021. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 16, 2024.
Employee # 4 has been in the position of counselor since March 4, 2013. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, however, it was not signed by the employee until March 6, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Gaudenzia Managers will ensure that Annual Performance Evaluations are completed, reviewed with the employee during a documented supervision session, and acknowledged via signature by both parties no later than February 1st of each year.
The Chief Executive Officer will ensure that this process is completed for the Project Director.
The Deputy Director will complete Annual Performance Evaluations for each of the Program Directors that they oversee and will also ensure that these Program Directors complete Annual Evaluations for the staff that they oversee.
The Quality Assurance department will review staff files during semi-annual program reviews to ensure compliance. |
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 a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 5 was admitted on February 9, 2024 and was active at the time of the inspection. Per a discussion with project staff, information such as client diagnosis was disclosed to the funding source, however, the consent to release information form to the funding source signed by the client on December 19, 2023, did not allow for the release of that information.
This is a repeat citation from the June 12, 2023, May 26, 2022, and June 10, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All current staff members with the responsibility for completion of releases will be scheduled to attend the web-based DDAP Confidentiality Training facilitated by DDAP. This will be completed no later than 7/31/24.
The Program Director will complete at least monthly audits of a sample of charts including a qualitative review of consent forms to ensure that all information is completed at admission, including the funding source.
The Quality Assurance department will conduct at least semi-annual audits, the results of which will be brought to the immediate attention of the Program Director to be addressed as described above. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of seven client records, the facility failed to follow their policy and procedures related to medication administration and recordkeeping in four out of seven records reviewed. The facility policy indicates that staff will document on the medication administration record (MAR) the reason a medication was not given.
Client # 1 was admitted on June 29, 2023 and was discharged on October 7, 2023. The MAR did not document the reason medications were not administered on September 21, 2023, September 23, 2023, September 24, 2023, and September 25, 2023.
Client # 2 was admitted on December 5, 2023 and was discharged on March 25, 2024. The MAR did not document the reason medications were not administered on December 25, 2023 through December 31, 2023, and January 21, 2024 through January 29, 2024.
Client # 4 was admitted on August 10, 2023 and was discharged on October 12, 2023. The MAR did not document the reason medications were not administered on August 15, 2023 through September 30, 2023 for one medication.
Client # 5 was admitted on February 9, 2024 and was active at the time of the inspection. The MAR did not document the reason medications were not administered on March 21, 2024 through March 31, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members with responsibility for administration and record keeping regarding medications will attend a Gaudenzia web-based training on medication documentation for Electronic Health Records. This training will be completed no later than 6/30/2024.
The Program Director will complete weekly audits of the MAR to ensure that documentation is entered properly into records. Any issues noted will be brought to the immediate attention of the staff members and corrected within 24 hours.
The Quality Assurance department will conduct at least semi-annual audits, the results of which will be brought to the immediate attention of the Program Director to be addressed as described above. |
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 a review of client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary within one week of discharge, in two of four applicable records reviewed.
Client # 1 was admitted on June 29, 2023 and was discharged on October 7, 2023. The discharge summary was not completed until October 27, 2023.
Client # 3 was admitted on December 14, 2023 and was discharged on February 18, 2024. The record did not contain a discharge summary.
This is a repeat citation from the June 12, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Completion of Discharge Summaries is the responsibility of the Primary Counselor assigned to the client. Discharge summaries are to be completed by the Primary Counselor and submitted in the EHR within 7 days of discharge. The Program Director will review client files at time of discharge to ensure that the information has been properly completed in discharge charts. The Program Director will review this requirement with all staff in an in-service training no later than 6/10/24.
The Program Director will complete at least monthly audits of a sample of charts. Any issues noted will be brought to the attention of the clinician and corrected immediately.
The Quality Assurance department will conduct at least semi-annual audits, the results of which will be brought to the immediate attention of the Program Director to be addressed as described above. |
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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in two of three applicable records reviewed.
Client # 3 was admitted on December 14, 2023 and was discharged on February 18, 2024. The record did not contain documentation of follow-up information.
Client # 4 was admitted on August 10, 2023 and was discharged on October 12, 2023. The record did not contain documentation of follow-up information.
This is a repeat citation from the June 12, 2023 and May 26, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up notes are to be completed by the assigned counselor within 7 days of scheduled aftercare appointment or within 30 days for all discharges. The Administrative Assistant will run a Detail of Discharge by Program Report from EHR noting which clients require a follow-up contact. This report will be reviewed with clinicians at weekly clinical meetings noting which clients are due for follow-up. Program Director will complete chart audit to ensure that this documentation is present in the EHR of member.
The Program Director will review this process with all staff in an in-service training no later than 6/10/24.
The Program Director will complete at least monthly audits of a sample of charts. Any issues noted will be brought to the attention of the clinician and corrected immediately.
The Quality Assurance department will conduct at least semi-annual audits, the results of which will be brought to the immediate attention of the Program Director to be addressed as described above. |
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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include verification that any work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in three of seven client records reviewed.
Client # 2 was admitted on December 5, 2023 and was discharged on March 25, 2024. The individual treatment and rehabilitation plan completed on January 4, 2024, did not include verification that work done by the client at the project is an integral part of treatment; however, the record contained evidence that the client did work at the facility.
Client # 3 was admitted on December 14, 2023 and was discharged on February 18, 2024. The individual treatment and rehabilitation plan completed on January 18, 2024, did not include verification that work done by the client at the project is an integral part of treatment; however, the record contained evidence that the client did work at the facility.
Client # 6 was admitted on February 29, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan completed on April 6, 2024, did not include verification that work done by the client at the project is an integral part of treatment; however, the record contained evidence that the client did work at the facility.
This is a repeat citation from the June 12, 2023 and May 26, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Work as treatment will be documented on all Treatment Plans as a Therapeutic Activities of Daily Living goal. Clinicians will identify and update work therapy assigned to the client as an integral part of their treatment plan.
The Program Director will review this requirement with all staff in an in-service training no later than 6/10/24.
The Program Director will complete at least monthly audits of a sample of charts. Any issues noted will be brought to the attention of the clinician and corrected immediately.
The Quality Assurance department will conduct at least semi-annual audits, the results of which will be brought to the immediate attention to the Program Director to be addressed as described above. |
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.
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Observations
Based on a review of client records, the facility failed to comply with plans of corrections that were approved by the Department.
A plan of correction for obtaining client signed consent to release information forms prior to disclosures of information was submitted and approved by the Department for the June 12, 2023, May 26, 2022, and June 10, 2021, annual licensing inspections. Obtaining client signed consent to release information forms prior to disclosing information was again found to be a deficiency in the April 29, 2024 licensing inspection.
A plan of correction for calling client emergency contacts within 12 hours of an Against Staff Advice discharge was submitted and approved by the Department for the June 12, 2023 and May 26, 2022, annual licensing inspections. Contacting emergency contacts was again found to be a deficiency in the April 29, 2024, licensing inspection.
A plan of correction for including follow-up information in the client record was submitted and approved by the Department for the June 12, 2023 and May 26, 2022, annual licensing inspection. Completing follow-up information was again found to be a deficiency in the April 29, 2024, licensing inspection.
A plan of correction for including verification of work therapy in the individual treatment and rehabilitation plan was submitted and approved by the Department for the June 12, 2023 and May 26, 2022, annual licensing inspection. Verification of work therapy on the individual treatment plans was again found to be a deficiency in the April 29, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is ultimately responsible for the implementation of the corrective action items detailed above.
The Program Director will complete monthly reviews of all POC items to ensure that they have been and continue to be implemented. Any issues noted will be addressed with the appropriate staff in a documented supervision session and corrected within 48 hours.
The Quality Assurance department will complete at least semi-annual reviews, which include review of any open corrective action plans, the results of which will be shared with the Program Director immediately to be addressed as noted above.
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