INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc., Vantage 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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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 upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt written plans that are consistent, with regard to the development of individualized treatment and rehabilitation plans.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant policies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis." These policies will be revised and approved by July 31st, 2012.
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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 upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
The Director of Finance and Accounting will coordinate with the external independent public accountant to ensure that all future financial audits are completed within required timeframes. This will be completed by December 31st, 2012 (6 months after June 30th; the close of our fiscal year) as per our policy.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure the facility was in good repair at all times.
The findings include:
A physical plant inspection was conducted on May 16, 2012 at 10:00 am. During the inspection at about 10:20 am it was found that the metal trim of the door to the handicap stall in the communal bathroom was partially detached and in need of repair. The trim stuck out about 6-8 " from the rest of the door and was a potential hazard to the clients, their children, or visitors.
The facility director was present during the inspection and confirmed the findings.
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Plan of Correction
On May 17, 2012 a second work order was submitted to our maintenance system requesting replacement of bathroom door in the upstairs handicap stall. The trim has been temporarily secured until the new door comes in or existing door is repaired. This will be completed by June 30, 2012.
To ensure that this does not happen again, maintenance runs are completed weekly. If there are safety issues, work orders are submitted immediately. Any safety issues, such as the trim of the door sticking out will be temporarily fixed immediately until the work order can be completed and processed.
Person Responsible: House Manager
Person Responsible for Monitoring: Program Director. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure fire extinguishers were inspected and approved annually.
The findings include:
A physical plant inspection was conducted on May 16, 2012 at 10:00 am. During the inspection at about 10:05 am it was found that the fire extinguisher in the rear of the kitchen had not been inspected since December 2010.
The facility director was present during the inspection and confirmed the findings.
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Plan of Correction
On May 17, 2012, the Fire Department came to inspect all fire extinguishers. They removed the outdated fire extinguisher in the kitchen and it has been replaced with a new updated fire extinguisher that is good until May of 2013.
The facility will ensure that this does not recur by checking all fire extinquishers immediately after they are replaced to ensure all extinguishers have been replaced and are up to date. Extinguishers will be checked on the maintenance run monthly.
Person Responsible: House Manage
Person Responsible for Monitoring: Program Director |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to maintain security screens or safety locks for all operable windows.
The findings include:
A physical plant inspection was conducted on May 16, 2012 at 10:00 am. During the inspection at about 10:27 am it was found that the none of the three windows in bedroom #10 had a security screen or safety lock in place.
The facility director was present during the inspection and confirmed the findings
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Plan of Correction
On May 17, 2012 a work order was put into the maintenance system requesting safety locks and/or screens for the windows in room 10. As of today, June 26, 2012, the screens have been placed in the windows.
All windows have been inspected to ensure that screens are in the windows or that the windows cannot be opened. All windows in the facility are secure.
Windows will be checked during the monthly maintenance run to ensure that screens are in place so that this deficiency will not reoccur.
Person responsible: House Manager
Person responsible for monitoring: Program Director. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to maintain protective caps over each electrical outlet.
The findings include:
A physical plant inspection was conducted on May 16, 2012 at 10:00 am. During the inspection at about 10:40 am it was found that three electrical outlets in the laundry room were uncovered.
The facility director was present during the inspection and confirmed the findings.
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Plan of Correction
On May 17, 2012, protective caps were put over the three electrical outlets in the laundry room.
Electrical outlets will be checked consistently when house maintenance runs are completed.
House maintenance runs are completed weekly and the electrical outlets will be consistently checked.
Person responsible: House Manager
Person responsible for monitoring: Program Director |
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
Based on a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's composite picture, assets and strengths, problems and needs, support systems, and coping mechanisms.
The findings include:
Five client records were reviewed for psychosocial evaluations on May 16, 2012. Five out of five client records lacked documentation of a psychosocial evaluation that included a clinical assessment, specifically client records #1, 2, 3, 4 and 5.
Client #1 was admitted to treatment on February 7, 2012. The psychosocial evaluation was completed on February 15, 2012 and did not include the client's composite picture or a clinical assessment of the client's assets and strengths.
Client #2 was admitted to treatment on February 21, 2012. The psychosocial evaluation was completed on February 23, 2012 and did not include a composite picture of the client.
Client #3 was admitted to treatment on August 29, 2011 and discharged on November 22, 2011. The psychosocial evaluation was completed on August 31, 2011 and did not include a clinical assessment of the client's assets and strengths, problems and needs, or coping mechanisms.
Client #4 was admitted to treatment on August 1, 2011 and discharged on February 6, 2012. The psychosocial evaluation was completed on August 5, 2011 and did not include a composite picture of the client or a clinical assessment of the client's assets and strengths.
Client #5 was admitted to treatment on September 16, 2011 and discharged on December 1, 2011. The psychosocial evaluation was completed on September 19, 2011 and did not include a composite picture of the client, a clinical assessment of the client's assets and strengths, support systems, or coping mechanisms.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
Starting June 13, 2012, all psychosocial evaluations will include an assessment of the client's composite picture, assets and strengths, problems and needs, support systems and coping mechanisms.
A training was conducted on June 12, 2012 to address the assessment portion of the psychosocial evaluation. This training included the specific areas to include the composite picture, assets and strengths, problems and needs, support systems and coping mechanisms. Assessment of the above was reviewed. The training was conducted by the Program Supervisor.
All paperwork, to include the psychosocial will be turned in weekly to the program supervisor to ensure that the paperwork is completed accurately and completely. This will ensure that this deficiency does not recur.
Person responsible: Program Supervisor
Person responsible for monitoring: Program Director |
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
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of treatment plans.
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) within 3-5 client days residential...."
Five client records requiring documentation of individualized treatment plans were reviewed on May 16, 2012. Five of five client records, specifically #'s 1, 2, 3, 4, and 5 contained treatment plans that were late.
Client #1 was admitted to treatment on February 7, 2012. The individualized treatment plan was due by February 12, 2012. The treatment plan was not completed until February 22, 2012.
Client #2 was admitted to treatment on February 21, 2012. The individualized treatment plan was due by February 26, 2012. The treatment plan was not completed until March 7, 2012.
Client #3 was admitted to treatment on August 29, 2011 and discharged on November 22, 2011. The individualized treatment plan was due by September 3, 2011. The treatment plan was not completed until September 12, 2011.
Client #4 was admitted to treatment on August 1, 2011 and discharged on February 6, 2012. The individualized treatment plan was due by August 6, 2011. The treatment plan was not completed until August 15, 2011.
Client #5 was admitted to treatment on September 16, 2011 and discharged on December 1, 2011. The individualized treatment plan was due by September 21, 2011. The treatment plan was not completed until September 29, 2011.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
Effective today, the individualized treatment plan shall be completed, approved and signed by the Counselor, Program Supervisor and Medical Director (when applicable) within 3 to 5 days of admission.
A training was conducted on June 12, 2012 addressing the need to complete treatment plan within 3 to 5 days of admission.
All paperwork will be turned in to the program supervisor on a weekly basis to ensure timeliness, accuracy and completeness.
Person responsible: Counselors
Person responsible for monitoring: Program Supervisor |
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
Based on a review of client records, the facility failed to document treatment plans to include the type and frequency of treatment and rehabilitation services.
The findings include:
Five client records were reviewed for treatment plans on May 16, 2012. Four out of five client records lacked documentation of a treatment plan that included the type and frequency of treatment and rehabilitation services, specifically client records # 1, 2, 3, and 5.
Client #1 was admitted to treatment on February 7, 2012. The treatment plan was completed on February 22, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted to treatment on February 21, 2012. The treatment plan was completed on March 7, 2012 and did not include the type and frequency of treatment and rehabilitation services.
Client #3 was admitted to treatment on August 29, 2011 and discharged on November 22, 2011. The treatment plan was completed on September 12, 2011 and did not include the type and frequency of treatment and rehabilitation services.
Client #5 was admitted to treatment on September 16, 2011 and discharged on December 1, 2011. The treatment plan was completed on September 29, 2011 and did not include the type and frequency of treatment and rehabilitation services.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
Effective 6/13/2012, all treatment plans will include the type and frequency of treatment rehabilitation services as indicated on the last page of the treatment plan.
A training was conducted on June 12, 2012 for all clinical staff to incluce the need to indicate the type and frequency of treatment rehabilitation services on the last page of the treatment plan. The training was conducted by the Program Supervisor.
All paperwork will be turned in weekly to the program supervisor to ensure accuracy, timeliness and completeness.
Person responsible: Counselors
Person responsible for monitoring: Program Supervisor |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services.
The findings include:
Five client records were reviewed for treatment plans on May 16, 2012. Four out of five client records lacked documentation of a treatment plan that included proposed types of supportive services, specifically client records # 2, 3, 4, and 5.
Client #2 was admitted to treatment on February 21, 2012. The treatment plan was completed on March 7, 2012; however it did not include a proposed type of support service for client #2.
Client #3 was admitted to treatment on August 29, 2011 and discharged on November 22, 2011. The treatment plan was completed on September 12, 2011; however it did not include a proposed type of support service for client #3.
Client #4 was admitted to treatment on August 1, 2011 and discharged on February 6, 2012. The treatment plan was completed on August 15, 2011; however it did not include a proposed type of support service for client #4.
Client #5 was admitted to treatment on September 16, 2011 and discharged on December 1, 2011. The treatment plan was completed on September 29, 2011; however it did not include a proposed type of support service for client #5.
The findings were reviewed with the facility director and clinical supervisor
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Plan of Correction
Effective June 13, 2012, treatment plans will include proposed types of supportive services needed for the individual client.
A training took place on June 12, 2012 to include a review of including proposed types of supportive services needed for individual clients to be put on the treatment plans.
All paperwork will be turned in to the program supervisor on a weekly basis to ensure accuracy, timeliness and completeness.
Person responsible: Counselors
Person responsible for monitoring: Program 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 in accordance with facility policy in one of four records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1's personnel record was reviewed. The project failed to develop an individual training plan annually in accordance with policy. Employee # 1 has been the Project Director since 1988 .Per policy, training plans will be conducted in January of each year. The facility failed to document an individual training plan in January for employee #1.
The findings were reviewed with the human resources staff.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
A training plan was completed for the corporate employee identified as deficient and dated in May 2012.
The Director of Training and the Director of Human Resources will ensure that all corporate staff complete an annual training plan as per organization policy in January of each year and will monitor ongoing conformance.
The Program Director will ensure that a training plan will be completed in January of each year per policy for each employee at the facility and will monitor ongoing conformance.
Target resolution date: Resolved. |