INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23 - 24, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. People With Hope/Short-Term Program 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the Project failed to ensure that each counselor assistant documented to the facility director that they were working toward counselor status in two of twelve records reviewed.
The findings include:
Twelve employees within the Project were required to document to the facility director that they were working toward counselor status upon completion of each calendar year. The Project failed to ensure that employee # 4 from the Coatesville Outpatient facility and employee # 4 from the People With Hope Inpatient facility were working toward counselor status.
Employee # 4 from Coatesville Outpatient was hired as a high school level counselor assistant on 6/21/2010. The facility failed to ensure that employee # 4 was working toward counselor status upon completion of the calendar year.
Employee # 4 from People With Hope Inpatient was hired as a high school level counselor assistant on 6/20/2011. The facility failed to ensure that employee # 4 was working toward counselor status upon completion of the calendar year. The personnel record included documentation from the facility director dated 4/7/2014 that stated: "During this training year in review employee # 4 has not taken any academic credits toward obtaining his degree. "
The findings were reviewed with Human Resource and the Facility Director.
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Plan of Correction
The Director of People with Hope will ensure that counselor assistants hired will satisfactorily complete one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) before they are promoted to the position of counselor.
On May 28, 2014, Counselor #4 will present a written plan to the People with Hope facility director that they are working toward counselor status per Division of Drug and Alcohol Licensure per DOH Policy 704.10: Counselor Assistant Promotion.
This information will be documented and updated upon completion of each calendar year by the director and counselor assistant.
Persons Responsible:
Division Director
People with Hope Program Director and Clinical Supervisor
Timeframe for Completion: May 28, 2014
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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 the physical plant inspection, the facility failed to keep frozen food at or below 0 degrees Fahrenheit in one of two freezers.
The findings include:
A physical plant inspection was conducted on April 24, 2014, at approximately 10:30 AM.
The freezer temperatures read 0 F degrees at the time of inspection. However, a review of the freezer temperature log, specifically for freezer # 1 indicated that the freezer measured above 0 F degrees for the entire month of March and April. Based on the temperature log, the average temperature for the month of March and April was 15 degrees Fahrenheit.
The Dietary Manager confirmed at the time of inspection that the freezers temperature exceeded 0 F for the month of March and April.
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Plan of Correction
On June 5, 2014 a training will be facilitated by the Food Service Manager with the staff on Division of Drug and Alcohol Licensure DOH Policy 705.7(b)(5): Food Service.
The freezer temperature will be monitored twice daily. Once in the morning and once in the evening to be in compliance with Policy 705.7 (b)(5)Food Service which states that that frozen food should be at or below 0F.
Persons Responsible:
Division Director
People with Hope Program Director
Food Services Manager
Timeframe: June 5, 2014
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record which included documentation that any work done by the client is an integral part of the treatment and rehabilitation plan in ten out of twelve client records reviewed.
The findings include:
Twelve client records were reviewed on April 23 - 24, 2014. The facility failed to document a complete client record that included documentation of work therapy as an integral part of treatment and rehabilitation in client records # 2, 3, 4, 5, 6, 7, 9, 10, 11 and 12.
The findings were reviewed with the Facility Director.
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Plan of Correction
A record-keeping training will be facilitated on June 5, 2014 to include any work done by the client will be an integral part of the treatment and rehabilitation plan as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.53(a): Complete Client Record.
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible:
Division Director
People with Hope Program Director and Clinical Supervisor
Timeframe for Completion: June 5, 2014
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