INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 24 - 25, 2012 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Gaudenzia Together 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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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 personnel record reviewed.
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.
The Project was previously cited for noncompliance with this standard.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented with all employees within required time frames. This will be completed by 1/31/2013, as per our policy. Program Director will be responsible for supervisory oversight and Division Director will be responsible for ongoing. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file. oversight. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
On May 24, 2012 copies of the staff CPR and First Aid cards and the April and May work schedule as provided by the facility were reviewed.
Findings:
Based on the work schedule and the CPR and First Aid cards provided by the facility, the facility failed to provide CPR and First Aid coverage on May 13, 2012 from 8 AM to 4 PM.
The Program Supervisor confirmed the findings.
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Plan of Correction
The program schedule was adjusted to esnusre that CPR and First Aid certified staff are available at all times on every shift. In addition staff will attend CPR First Aid training as required by agency policy. Program Director will be responsible for supervisory follow up and Division Director will be resonsible for ongoing oversight. Full compliance will be met 07/01/2012. |
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 observation during a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The findings include:
On May 24, 2012, a physical plant inspection was conducted at approximately 10:30 AM.
It was observed that the hallway in the vicinity of the counseling offices had stained/ water damaged ceiling tiles.
The Facility Director confirmed the findings.
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Plan of Correction
These ceiling tiles in addition to any other ceiling tiles that appeared to have water damage have been replaced. Program Director will be responsible for completing weekly inspections for supervisory follow-up. Division Director will be responsible for ongoing monthly oversight and inspections. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain counseling areas with furnishings which are in good repair.
The findings include:
On May 24, 2012, a physical plant inspection was conducted at approximately 10:30 AM.
It was observed that two out of two offices in the the counseling area, had stained/ water damaged ceiling tiles.
The Facility Director confirmed the findings.
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Plan of Correction
These ceiling tiles in addition to any other ceiling tiles that appeared to have water damage have been replaced. Program Director will be responsible for completing weekly inspections for supervisory follow-up. Division Director will be responsible for ongoing monthly oversight and inspections. Full compliance will be met 6/15/2012. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
On May 24, 2012, a physical plant inspection was conducted at approximately 10:30 AM.
The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The sixth floor has two resident bathrooms.
It was observed in one of the bathrooms that two out of two showers were out of order.
The Facility Director confirmed the findings. He stated that one shower leaked to the floor below, and the other shower was being repaired at the time of inspection.
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Plan of Correction
Both of these showers have been repaired and are in good working order. Program Director will be responsible for supervisory follow up and weekly inspection. Division Director will be responsible for ongoing oversight. Full compliance will be met as of 6/15/2012. |
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 consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
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 Individual 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. Full compliance will be met 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 coordiante 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. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in one of seven client records reviewed.
The findings include:
On May 24 - 25, 2012, seven client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 4 Pa. Code 255.5. The facility failed to adhere to the requirements specified at 4 Pa. Code in one of seven records, specifically client record # 5.
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client # 5 was admitted to the program on 3/14/12.
The facility did not obtain a valid consent to release confidential information; the facility released to a government agency a form that did not adhere to the requirements specified at 4 Pa. Code 255.5 as it revealed the substance currently being used by client # 5 and the frequency.
The Program Supervisor confirmed the findings.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will include confidentiality and the restricitions that apply to voluntary consent. These restricitions are limited to the following:
1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Program Supervisor will be responsible for providing monthly supervisory follow up and Program Director will be responsible for ongoing oversight. In regard to client record # 5 an updated consent could not be completed due to the client no longer being at the program. Full compliance will be met effective July 31, 2012.
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709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in one of seven client records.
The findings include:
On May 24 - 25, 2012, seven client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 28 Code 709.28 and 42 CFR Part II subpart C subsection 2.31 (b). The facility failed to adhere to the requirements specified at 28 Pa. Code in one of seven records, specifically client record # 9.
28 Pa. Code 709.28 states:
The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
Client # 9 was admitted to the program on 3/29/12.
A signed "Consent to Release Information" form documented on 5/9/12, to a government agency, failed to indicate what information would be disclosed.
The Program Supervisor confirmed the findings.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will focus on the requirements to obtain for each client an informed voluntary consent from the client for the disclosure of information contatined in the client record. Program Supervisor will be esponsible for monthly Suervisory follow up and Program Director will be responsible for ongoing oversight. In regard to client record # 9 an updated consent could not be completed because the client is no longer at the program. Full compliance will be met July 31, 2012. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual, administrative documentation, and a conversation with nursing staff, the facility failed to document inspection of the storage area according to policy.
Findings:
The facility policy states: "The drug storage area and medications shall be inspected by a registered pharmacist per agreement who comes on site at least monthly. The Medication and Drug Storage Inspection form shall be completed monthly by the pharmacist conducting the inspection and by the nurse who accompanies him/her during the inspection."
On May 24, 2012 a physical plant inspection was conducted at approximately 10:30 AM.
Based on a review administrative documentation and a conversation with nursing staff; the facility did not comply with the policy and procedures manual as the pharmacist does not come on site monthly to inspect storage area, rather the storage area inspection is conducted in house by nursing staff.
The head nurse confirmed the findings.
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Plan of Correction
This policy has been revised in the Gaudenzia Policy and Procedure manual by the Quality Improvement Director. The policy has been reviewed by necessary staff and states that the inspection of medication storage area will be conducted internally by a qualified health care professional such as a licensed nurse and will be overseen by the Director of Nursing. Changes to the policy will be reviewed and approved by the Board of Directors. Full compliance will be met by July 31, 2012. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in three of six records reviewed.
The findings include:
On May 24 - 25, 2012, six records requiring documentation of the client's medical history were reviewed. The facility failed to document a medical history in three of six records reviewed, specifically client records # 7, 8, and 9.
Client # 7 was admitted to the program on 3/8/12.
Client record # 7 did not include a medical history at the time of review on 5/25/12.
Client # 8 was admitted to the program on 3/9/12.
Client record # 8 did not include a medical history at the time of review on 5/25/12.
Client # 9 was admitted to the program on 3/29/12.
Client record # 9 did not include a medical history at the time of review on 5/25/12.
The Program Supervisor did not dispute the findings.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will focus on the requirement to complete a medical history in accordance with this standard. Program Supervisor will be responsible for monthly supervisory follow up and Program Director will be responsible for ongoing oversight. In regard to client record # 7,8,9, medical histories were not complete due to the client no longer being at the program. Full compliance will be met July 31, 2012. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records and a review of the project's policy and procedures manual, the facility failed to document a record of services provided in three of six records reviewed.
The findings include:
The project's policy states: "Record of Services: All services rendered to a client shall be documented on the Record of Services form, which is maintained in the client record. The form should initially be completed with the intake paperwork. The Counselor or staff person scheduled to provide a service shall record the date a service is scheduled to be provided, the specific service and the initials of the staff responsible for the service. Documentation of this should be made promptly after the appointment is scheduled. The client's attendance status and the duration of the service shall be noted as soon as the disposition is known. A ROS is completed daily."
On May 24 - 25, 2012, six client records requiring documentation of record of services provided were reviewed.
The facility failed to document a record of services provided in three of six records reviewed, # 1, 8, and 9.
Client # 1 was admitted to the program on 2/23/12.
Client # 1's record did not contain a record of service at the time of review on 5/25/12.
Client # 8 was admitted to the program on 3/9/12.
Client # 8's record of service documented two dates, 3/13/12 and 4/24/12.
Client # 9 was admitted to the program on 3/29/12.
Client # 9's record did not contain a record of service at the time of review on 5/25/12.
The Program Supervisor did not dispute the findings.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will focus on the requirement to document a record of service as required by this standard. Program Supervisor will be responsible for monthly supervisory follow up and Program Director will be responsible for ongoing oversight. Full compliance will be met July 31,2012. |
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 and a review of the facility's policy and procedures manual, the facility failed to document follow-up information in one of five records reviewed.
The findings include:
The facility policy states:
"In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who neither are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note remember to state the reason for the refusal in the note and on the form.
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow up Log binder."
On May 25, 2012, five client records requiring documentation of follow-up information were reviewed. The facility failed to document follow-up information in one of five records reviewed, specifically client record # 5.
Client # 5 was admitted to the program on 3/14/12 and discharged on 3/16/12.
The facility did not document follow-up information at the time of review on 5/25/12.
The Program Supervisor confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will focus on the requirement to document follow up as required by this standard. Program Supervisor will be responsible for conducting weekly supervisory follow up and Program Director will be responsible for conducting ongoing oversight. This supervisory follow-up and ongoing oversight has been increased and will be documented on a follow up log audit form due the this facility being previously cited for noncompliance with this standard during 2011 licensure inspection. In regard to client # 5 follow up was conducted. Full compliance will be met July 31, 2012. |