INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 15, 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. Integrity 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of four personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training in the use of the fire extinguishers upon staff employment.
Employee #2 was hired on January 15, 2024 for the position of facility director and was still employed at the time of the inspection. Employee #2 did not have the training until April 5, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 was hired on January 15, 2024 for the position of facility director and was still employed at the time of the inspection. Employee #2 did not have the training until April 5, 2024.
The program director has completed the Fire Extinguisher training.
In the future, the Deputy Regional Director will ensure the training is completed in orientation or within seven days after orientation. This will occur with the Program Director in Supervision to review training requirements and progress toward completion. This will be documented in a supervision note. Any staff member found to be out of compliance with training requirements will have this rectified within 48 hours.
Quality Assurance Staff will complete at least semi-annual reviews of the program, including review of training records. Any issues noted will be brought to the immediate attention of the Program Director to be addressed as noted above.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of four personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee on shift was trained to perform assigned tasks during emergencies.
Employee #2 was hired on January 15, 2024 for the position of facility director and was still employed at the time of the inspection. Employee #2s training did not occur until April 11, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 was hired on January 15, 2024, for the position of facility director and was still employed at the time of the inspection. Employee #2 did not have the training until April 11, 2024.
The program director has completed the Fire Safety training.
In the future, the Deputy Regional Director will ensure that the training is completed within the first seven days after orientation. The Deputy Regional Director will meet bi-monthly with the Program Director in Supervision to review training requirements and progress toward completion. This will be documented in a supervision note. Any staff member found to be out of compliance with training requirements will have this rectified within 48 hours.
Quality Assurance Staff will complete at least semi-annual reviews of the program, including a review of training records. Any issues noted will be brought to the immediate attention of the Program Director to be addressed as noted above.
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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 four 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 on September 9, 2019 as the project director and is still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024.
Employee #3 was hired on October 24, 1994 as a counselor and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until April 5, 2024.
Employee #4 was hired on March 15, 2016 as a counselor and was still in that position at the time of the inspection. The annual work performance was not competed until April 5, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #1 was hired on September 9, 2019 as the project director and is still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024.
Employee #3 was hired on October 24, 1994 as a counselor and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until April 5, 2024.
Employee #4 was hired on March 15, 2016 as a counselor and was still in that position at the time of the inspection. The annual work performance was not competed until April 5, 2024.
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 Directors will ensure that this process is completed for all Division Directors.
The Division Directors will complete Annual Performance Evaluations for each of the Program Directors that they oversee, and will also ensure that these Program Directors complete Annual Performance Evaluations for the staff that they oversee.
The Quality Assurance department will review staff files during semi-annual program reviews to ensure compliance.
2/1/25
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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 records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #7 was admitted on February 8, 2024 and discharged on March 30, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #7 was admitted on February 8, 2024 and discharged on March 30, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
An in-service training will be held by the Program Director on how to complete releases and the limitations of releases as it pertains to state regulations. This will occur no later than 5/31/24. Program Director and Clinical Supervisor will complete at least monthly audits of a sample of charts to ensure that this is completed correctly and in a timely manner. Any issues noted will be addressed with the clinician in a documented supervision session and corrected within 48 hours.
The Quality Assurance department will audit charts during semi-annual program reviews to ensure compliance. Any issues noted will be brought to the immediate attention of the Program Director to be addressed as noted above.
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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.
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Observations
Based on a physical plant inspection on April 15, 2024, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was a bottle of alcohol, a bottle of peroxide and wound wash stored with the oral medication in the medication cart.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a physical plant inspection on April 15, 2024, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was a bottle of alcohol, a bottle of peroxide and wound wash stored with the oral medication in the medication cart.
The drugs for external use will be stored separately from oral medications. Medication Inspections will be conducted on a monthly basis and will be filed in a binder for this purpose. This inspection will be conducted by the Administrative Coordinator and documented in a spreadsheet. The Program Director will monitor compliance via quarterly review of the binder and checks of the medication area.
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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 client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in one out of seven client records.
Client #2 was admitted on February 1, 2024 and was still active at the time of the inspection. Client #2 was prescribed two different medications and the prescriptions stated that one tablet was to be taken in the morning. The medication administration records showed that the medications were not given on the morning of April 7, 2024. There was no additional documentation included indicating a reason why the medications were not given as prescribed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in one out of seven client records.
Client #2 was admitted on February 1, 2024 and was still active at the time of the inspection. Client #2 was prescribed two different medications and the prescriptions stated that one tablet was to be taken in the morning. The medication administration records showed that the medications were not given on the morning of April 7, 2024. There was no additional documentation included indicating a reason why the medications were not given as prescribed.
Medication retraining will be held no later than 5/31/24. The training will include a review of the state regulations for Medication Control, a review of how and where to document the MAR's when a client receives their prescribed medication, a review of how and where to document the MAR's when a client refuses their prescribed medication and a review of how and where to initial the MAR's.
The Program Director will be responsible for ensuring that this plan of correction is being implemented and followed by conducting a daily (Monday to Friday) inspection of all electronic MAR's. On Mondays the director will review Saturday, Sunday, and Monday. This inspection will ensure that all MARs have been correctly and completely documented. Any issues in documentation noted will be addressed with the staff member in a documented supervision session and corrected immediately.
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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 treatment plan updates within the facility ' s policy timeframe of every thirty days in four out of five applicable records reviewed.
Client #1 was admitted on December 4, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 6, 2023, and the next update was due no later than January 6, 2024; however, it was not completed until January 10, 2024. A treatment plan was completed on February 8, 2024, and the next update was due no later than March 8, 2024; however, it was not completed until April 8, 2024.
Client #3 was admitted on February 5, 2024 and was still active at the time of the inspection. A treatment plan was completed on February 22, 2024, and the next update was due no later than March 22, 2024; however, there was no documentation that one was completed.
Client #6 was admitted to on November 1, 2023 and discharged on February 6, 2024. A treatment plan update was completed on November 29, 2023, and the next update was due no later than December 29, 2023; however, it was not completed until January 3, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 was admitted on December 4, 2023 and was still active at the time of the inspection. A treatment plan was completed on December 6, 2023, and the next update was due no later than January 6, 2024; however, it was not completed until January 10, 2024. A treatment plan was completed on February 8, 2024, and the next update was due no later than March 8, 2024; however, it was not completed until April 8, 2024.
Client #3 was admitted on February 5, 2024 and was still active at the time of the inspection. A treatment plan was completed on February 22, 2024, and the next update was due no later than March 22, 2024; however, there was no documentation that one was completed.
Client #6 was admitted to on November 1, 2023 and discharged on February 6, 2024. A treatment plan update was completed on November 29, 2023, and the next update was due no later than December 29, 2023; however, it was not completed until January 3, 2024.
An internal tracking tool for each chart has been developed to help remind staff of upcoming documentation requirements, including treatment plan updates. The Program Director will send a reminder to clinicians at the beginning of each month noting which clients are due for Treatment Plan updates. Clinical staff will send all treatment plans to Program Director for approval. Calendars are being utilized to keep close track of time-sensitive dates for each client. Upcoming treatment plan updates will be reviewed in weekly Clinical Staff meetings.
The Clinical Supervisor will conduct weekly audits of a sample of charts in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
The Program Director will conduct monthly audits of a sample of charts in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the Clinical Supervisor in order to follow up with the clinician in supervision and completed within 48 hours.
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