INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 28, 2017 through June 29, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia, Inc. Broad Street 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel records, the facility failed to document the completion of 25 clock hours of annual training required for 1 employee for the training year 01/01/16 through 12/31/16.
Employee #4 was hired as a counselor on 4/7/14 and was still in that position at the time of inspection. The record for employee #4 only included documentation of 13.5 hours of annual training for the training year reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff personnel files will be reviewed a minimum of once/month by the Administrative Assistant and Program Director to review training documentation. Clinical/Program Supervisors will review training needs with staff monthly during individual supervision. Accrual of training hours for each staff will be reviewed quarterly by the Facility Director to ensure all staff meet required training hours each training year. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection on June 29, 2017 at approximately 10:00 A.M., the facility failed to ensure that all heaters in the facility were permanently mounted or installed. A space heater was found in an unoccupied counselor office in the basement.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heater was removed from the facility on 6/30/2017. The Facility Director will conduct weekly facility checks to ensure that all heaters in the facility are permanently mounted or installed. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection conducted on June 29, 2017 at approximately 10:00 am, it was observed that the facility failed to ensure that all interior exits and stairs were lit at all times. The basement stairway leading outside to Broad Street did not have an operable light fixture and the short hallway was pitch black at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The basement stairway light fixture was repaired on 7/6/2017 by the Gaudenzia, Inc. Maintenance Department. As ongoing monitoring, all facility issues will be communicated by the Facility Director to the Maintenance department within 24 hours of finding. The Facility Director or Division Director will follow up with the Maintenance Dept. Director on all facility-related issues on weekly basis until resolved. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on June 29,2017, it was discovered that the facility failed to maintain patient records in locked storage containers at all times. The intake specialist's office located in the basement of the facility had discharged client files throughout the room that were not locked in storage containers.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Intake Specialist moved to a new office location on 7/7/2017. All client files were secured in locked storage cabinets. The Facility Director will conduct weekly facility checks to monitor compliance with storage of patient records. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 3 of 8 client records. Additionally, 5 of 8 client records had consent to release forms that were missing elements.
Client #1 was admitted on 9/6/16 and was discharged on 9/13/16. There was documentation of correspondence with a government agency on 9/12/16 and 9/13/16; however, there was no consent to release form signed by the client prior to disclosure. Additionally, there were two consent to release forms signed and dated by the client on 9/6/16 but they did not include the name of a person, agency or organization to whom disclosure would be made to.
Client #2 was admitted on 6/14/16 and was discharged on 9/26/16. There was a consent to release form signed and dated by the client on 6/14/16 to the funding source, but the form did not include the specific information to be disclosed.
Client #3 was admitted on 5/8/17 and was still an active client at the time of the inspection. There were consent to release forms signed and dated by the client on 5/8/17 and 6/2/17 to a family member and an external agency, but both forms did not include the specific information to be disclosed and the purpose for the disclosure.
Client #7 was admitted on 4/25/17 and was an active client at the time of the inspection. There was a consent to release form signed and dated by the client on 4/25/17, but the form did not include the name of a person, agency or organization to whom disclosure would be made to and the client's signature was not dated. Additionally, there as a consent to release form dated 4/25/17 to the primary care physician, but the form did not include the dated signatures of both the client and witness.
Client #8 was admitted on 5/25/17 and was an active client at the time of the inspection. There was a facsimile sent on 6/6/17 to an outside entity; however, there was no consent to release form signed by the client prior to disclosure. Additionally, there was a consent to release form dated 5/25/27 to the funding source, but it did not include the date of the client's signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director/Division Director completed an in-service on consents for Release of information on 7/13/2017. The Broad St Program/Clinical Supervisor(s) will conduct chart reviews during staff supervisions to monitor compliance. The Facility Director will conduct a random review of open charts on a monthly basis to monitor compliance.
Client #3 was discharged from the facility on 6/29/17 prior to receipt of this plan of correction.
Client #7- the consent to release form that was signed on 4/25/17 but did not include the name of a person or agency to whom disclosure would be made was removed from the client record on 7/6/17. The consent to release form dated 4/25/17 to the primary care physician was signed by the client and witness on 7/20/17.
Client #8- a consent to release form for an external organization was signed and dated by the client and witness on 7/19/17. The information requested was re-sent on 7/20/17. The consent to release form dated 5/25/17 to the funding source was dated by the client on 7/19/17. |
709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document long-term goals for treatment as formulated but both staff and client in the individual treatment and rehabilitation plans in 5 of 6 client records
Client #1 was admitted on 9/6/16 and was discharged on 9/13/16. The comprehensive individual treatment and rehabilitation plan was completed on 9/12/16.
Client #2 was admitted on 6/14/16 and was discharged on 9/26/16. The comprehensive individual treatment and rehabilitation plan was completed on 7/3/16.
Client #3 was admitted on 5/8/17 and was an active client at time of inspection. The comprehensive individual treatment and rehabilitation plan was completed on 5/9/17.
Client #7 was admitted on 4/25/17 and was an active client at time of inspection. The comprehensive individual treatment and rehabilitation plan was completed on 5/30/17.
Client #8 was admitted on 5/25/17 and was an active client at time of inspection. The comprehensive individual treatment and rehabilitation plan was completed on 6/12/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #3 was discharged from the facility on 6/29/17.
Client #7- The individual treatment plan updated on 7/20/17 includes long-term and short-term goals.
Client #8- The individual treatment plan was updated on 7/12/17 and includes long-term and short-term goals.
The Facility Director/Division Director completed an in-service on Tx Plan development on 7/13/2017 to review the requirement to include short and long-term goals for treatment as formulated by both staff and client. All clinical documentation, including treatment plans, is reviewed and approved by the Program/Clinical Supervisor(s) prior to submission for filing in the client record. The Facility Director will conduct a random review of open charts on a monthly basis to monitor compliance. |
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 provide a complete client record in 5 of 8 client records.
Client #1 was admitted on 9/6/16 and was discharged on 9/13/16. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #2 was admitted on 6/14/16 and was discharged on 9/26/16. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection. Additionally, the client record did not include any documentation of follow-up information.
Client #5 was admitted on 10/13/16 and was discharged on 5/2/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #6 was admitted on 8/2/16 and was discharged on 8/31/16. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #8 was admitted on 5/25/17 and was an active client at the time of the inspection. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #8- The individual treatment plan was updated on 7/12/17 and includes verification that work done by the client is a part of treatment and rehabilitation.
The Facility Director/Division Director completed an in-service on 7/13/2017 on the formulation of treatment plans to include work done by the client. All clinical documentation, including treatment plans, is reviewed and approved by the Program/Clinical Supervisor(s) prior to submission for filing into the client record. The Facility Director will conduct a random review of open charts on a monthly basis to monitor compliance. |