INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on June 8 - 9, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on July 10, 2010.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the policy and procedure manual, and an interview with the facility director, the facility failed to document a mechanism to collect feedback on completed training in one of two personnel records as required.
The findings include:
Five personnel records were reviewed on May 4 - 7, 2010.
Two personnel records were required to contain documented feedback forms after the completion of training.
The facility failed to document the feedback forms after the completion of employee training in personnel record # 2.
The facilities policy states:
All staff members are required to complete a Staff Training Evaluation at the conclusion of all in-house and outside training. Staff Training Evaluation Sheets are to be given to the Program Director.
The facility director confirmed during an interviewed on June 8, 2010 that feedback forms were not documented on completed training.
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Plan of Correction
Program director and administrative coordinator will review trainings attended by staff and monthly evaluations to ensure that training are completed and filed in personnel charts and filed by months end. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the facilities training files it was determined that the facility director did not have the minimum training hours for the 2009 annual training year.
The findings include:
A review of the facility director' s training file revealed that the required twelve clock hours of training annually was not complete.
The facility only had documentation verifying that the facility director only completed 9.5 training hours for the year.
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Plan of Correction
Program Director has been given required training hours standards for all positions at Washington House. As part of monthly reporting, Program Director will list training for each staff quarterly and report out in monthly facility narritive. Administrative coordinator will ensure registrations for trainings and filing of training certificate in personnel charts monthly. |
705.5 (c) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(c) No more than four residents may share a bedroom.
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Observations
Based on a physical plant inspection conducted on June 9, 2010, and confirmation by the facility director, the facility failed to ensure that no more than four residents may share a bedroom.
The findings include:
At approximately 11AM during the physical plant tour it was observed that there were five beds in bedroom # 5.
The facility director stated that the bedroom has five beds and five residents.
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Plan of Correction
Revised response to PO33-
Until 1st floor is renovated and can be inspectedby DOH,capacity will be taken to 23 for 2nd floor. Each room on 2nd floorwill have no more than 4 beds. |
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
Based on a review of client records, the facility failed to document a treatment plan update on the client's progress in relationship to the stated goals identified in the individual treatment and rehabilitation plan in four of thirteen records reviewed.
The findings include:
Fourteen client records were reviewed on June 8 - 9, 2010.
Thirteen records required documentation of a treatment plan update that includes an assessment of the client's progress as it relates to the the goals identified in the individual treatment and rehabilitation plan.
The facility did not document an assessment of progress in the treatment plan update in four of 13 client records, # 3, 12, 13, and 14.
The facility's policy states:
Individualized treatment plans shall be formally updated every 30 days (residential) or 60 days (outpatient IOP ) and 90 days ( Outpatient) utilizing a treatment plan update form. For the Short Term Programs, updates will occur every 15 days.
During clinical staff meeting, the primary counselor shall present a verbal case report for team consultation at least weekly. Treatment progress shall be documented on the case consultation form.
Depending on client progress and recommendations of the clinical team, goals may be deleted, added or revised as needed. The client problem list will be reviewed and discussed with the addition or revision of the client ' s goal. Documentation shall be made on the original treatment plan or updated treatment plan accordingly.
Client # 3's individual treatment plan was complete on 12/31/09, the updates were complete on 1/29/10, 2/26/10, and 3/26/10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
Client # 12's individual treatment plan was complete on 4/27/10, the update was complete on 5/27/10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
Client # 13's individual treatment plan was complete on 3/24/10, the updates were complete on 4/23/10 and 5/21/10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
Client # 14's individual treatment plan was complete on 2/25/10, the updates were complete on 5/21/10, 4/23/10 and 3/25/10, but did not include an assessment of progress in relation to the stated goals of the individual treatment plan.
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Plan of Correction
There is a treatment plan training scheduled for 7/1/10 for the clinical staff. Treatment plans will include comments on achieved and unachieved goals and reviewed agin in an individual progress note when the counselor is in session with the client. Clinical Supervisor will review plans monthly for compliance. Case consultations are done for every client once within the first 30 days after admission and every sixty days thereafter for the halfway house level of care. Achievement of goals can also be commented on during case consultation. |
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 the review of client records and the facility's policies and procedures manual, the facility failed to document a complete client record which included a discharge summary in two of five client records reviewed.
The findings include:
Five closed client records were reviewed on June 8 - 9, 2010 for discharge summaries.
The facility failed to document a discharge summary per policy in two of five client records, specifically # 1 and 2.
The facility's policy states:
Within one week after discharge, there should be entered into the client ' s chart a discharge summary describing the reasons for treatment, services offered, response to treatment and the client ' s status or condition upon discharge.
The discharge summary shall be maintained in the client record.
Client # 1 was admitted to the program on 2/25/10 and discharged on 5/11/10.
The discharge summary was not documented at the time of review on 6/8/10.
Client # 2 was admitted to the program on 5/3/10 and discharged on 5/7/10.
A discharge summary was not documented at the time of review on 6/8/10.
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Plan of Correction
The discharge summary is part of the client record from the time that the client enters treatment. The Clinical Supervisor will review discharge summaries at discharge to insure completeness. This will be reported out on as part of the facilities CQI report monthly. |
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, an interview with the facility director, and a review of the policy and procedures manual, the facility failed to document follow-up within 7 days in three of five client records.
The findings include:
Fourteen client records were reviewed on June 8 - 9, 2010.
Four client records required documentation of follow-up information.
The facility did not document follow-up information within 7 days from the date of discharge, as per facility policy, in client records # 1, 2, and 4.
The facility's policy states:
20. Follow Up: Within seven (7) days of the date of a referral appointment made for a client
leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate. In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted directly by the counselor or supervisor ' s designee to determine the client ' s well-being and to maintain the opportunity for re-admission should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder.
Client # 1 was admitted to the program on 2/25/10 and discharged on 5/11/10, follow-up was not documented at the time of review on 6/8/10.
Client # 2 was admitted to the program on 5/3/10 and discharged on 5/7/10, follow-up was not documented at the time of review on 6/8/10.
Client # 4 was admitted to the program on 1/29/10 and discharged on 4/14/10, follow-up was not documented at the time of review on 6/8/10.
The facility director confirmed that no contact was made with the clients.
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Plan of Correction
The follow-up contact log will be given to the clinical supervisor to complete as of 7/1/2010. The supervisor will complete the log within 7 days from the date of discharge. The Administrative coordinator will review the log on a weekly basis to ensure discharges have been contacted. The Director will do a monthly log audit by the 30th of each month to ensure compliance. In all cases not documented at Washington House, the client left no forwarding phone number and cannot be reached. In the future, the Clinical Supervisor will contact the emergency contact given or the case manager. |
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 the review of client records, the standards for inpatient non-hospital activities, and an interview with the facility director, the facility failed to verify that any work done by the client is an integral part of the treatment and rehabilitation plan in ten of thirteen client records reviewed.
The findings include:
Fourteen client records were reviewed on June 8 - 9, 2010.
Thirteen client records required documentation of work therapy in the treatment plan.
The facility did not document work therapy in the comprehensive or treatment plan updates in client records # 1, 3, 4, 5, 9, 10, 11, 12, 13, and 14.
Standard 709.53(a)(12) states:
Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
An interview with the facility director confirmed that client's participate in work outside of cleaning their personal space and that documentation has not been done.
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Plan of Correction
Work therapy is an essential part of a client's development during their stay in a therapeutic community. One counselor did have work therapy on her treatment plans, unfortunately the other counselors did not. Leslie Ziegler, Program Director at Winner and previous Director at Washington House will do a training with Washington House's clinical staff to insure that work therapy is a goal on every treatment plan. Training will occur on 7/1/2010. Patricia Evans, Clinical Supervisor at Washington House will review each update monthly and insure work therapy is a goal. If work therapy is not on the update, it will not be signed off on and will be given back to the counselor to add. This begins with all treatment plans scheduled to be updated in July, 2010. |