INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2007 through September 12, 2007 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 October 15, 2007.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of administrative documentation and personnel information on 9/11/2007, the facility failed to document weekly close supervision for employee #5. Supervision notes were documented only monthly on the following dates: 1/04/2007, 2/02/2007, 3/06/2007, 4/09/2007, 5/09/2007, 6/21/2007, 7/11/2007 and 8/17/2007.
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Plan of Correction
Program Director will supervise Counselor Asst. on a weekly basis for at least 9 months at which time a preformance evaluation will indicate counselor Asst. competency.
Responsible: Program Director 9/17/07
A monthly internal audit of the Counselor Asst's personnel chart will be done by the Clinical Supervisor to insure supervisions are documented for each week until 9/17/07
Future Counselor Assistants will have documented weekly supervisions that will be reviewed in internal audits by the Program Director and Administrative Coordinator as per standard 704.9. The documented weekly supervision notes will be kept in the personnel file on-site with copies sent to the Corporate Office for their files. |
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 personnel and training records on August 14, 2007, the facility failed to document 12 hours of training for employee #2. Only 1 hour of training was documented for the 2006 training year.
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Plan of Correction
Employee#2 will receive 12 hours of training.
Responsible: Program Director and Administrative Coordinator
Training hours are reported in CQI - training will be tracked on a monthly basis. Program Director and the Administrative Coordinator will review employee#2 training hours monthly through internal audit and report out in monthly CQI staff training report.
Individual training plan created by the Division Director and Program Director will be done each year in January with training registrations turned in at that time. Monthly internal audit by the Admin. Coordinator will insure compliance with the training plan. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill log on 9/11/2007, the facility failed to document whether or nor the fire alarm or the smoke detector was set off for three of three fire drills conducted during the month of November 2006.
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Plan of Correction
The documentation of the fire alarm or smoke detector being set off will be presented in the monthly CQI under aspects of care - fire safety.
Responsible: Clinical Supervisor 12/20/2007. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on a review of administrative documentation, the facility failed to include a statement of activities and accomplishments for the facility for the preceding year.
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Plan of Correction
The annual report for the FY07 will be printed and available for the current FY and every year thereafter and will include activities and accomplishments for the previously FY.
Responsible: Director of Administration
9/26/2007 |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation, the facility failed to include available resources and time frames for achievement of the stated goals and objectives.
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Plan of Correction
Executive staff who are responsible for the specific goal areas will develop and revise plans in specific goal areas in consultation with their respective Board Committees and available resources for approval at the September Board meeting and every September thereafter.
Responsible: Executive Staff 9/16/2007 |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative documentation, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
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Plan of Correction
A written agreement for 24 hour ER medical coverage has been sent to Methodist Hospital (9/11/07) and is expected back by 10/15/2007.
Responsible: Program Director 10/15/2007 |
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, the facility failed to comply with the restriction imposed at 4 Pa. Code, Subsection 255.5 (b). The facility documented that "any other information that's relevant to client's treatment" would be released to the client's Intermediate Punishment Program worker and "other information to receive benefits" to the Department of Public Welfare in two of four client records reviewed, #1 and 2.
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Plan of Correction
The Clinical Supervisor will review 4PA code subsection 255.5 (b) with all staff. All staff will review the PA confidentiality and 709.28 regs.
Responsible: Program Director 9/14/2007 |
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 administrative policy and procedure and medication inspection records, the facility failed to conduct monthly inspections of the medication storage area as stated in the project's policy.
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Plan of Correction
The facility nurse will conduct monthly inspections and state that the monthly inspection was done on the monthly facility health report that is part of the facility's monthly CQI report. The report will be reviewed and signed off by the Program Director. The Program Director will then verbally report out that the inspection was done to the CQI DIrector in the monthly CQI meeting.
Monthly inspections will be monitered via CQI - will moniter for next 3 months.
Responsible: Program Director
Program Nurse
Director CQI
12/20/07 |
709.32(c)(4) 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:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of administrative policy and procedure and medication administration records, the facility failed document when, and if, clients received medications as prescribed in four of six client records reviewed, #1, 4, 5 and 6.
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Plan of Correction
The medication policies 709.32 will be reviewed with the Nurse and clinical/house manager staff. The Clinical Supervisor will audit the MAR for completeness. The audit results will be monitered in the monthly CQI meeting for 3 months.
Responsible: Clinical Superviosor
Nurse
Director CQI
2/15/2008 |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a complete psychosocial evaluation in three of four client records reviewed, #1, 2, and 4. Psychosocial evaluations did not include a composite picture that identified the client's support systems, coping mechanisms, and attitude towards treatment.
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Plan of Correction
Staff will attend the next record keeping training. The Clinical Supervisor will moniter psychosocial evaluations and a composite picture that identifies the client's support systems and coping mechanisms, attitudes on a weekly basis. Results will be presented in CQI x 4 months.
Responsible: Clinical Supervisor
Program Director
1/30/2008 |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of the treatment and rehabilitation services in four of four client records reviewed, #1, 2, 3 and 4.
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Plan of Correction
The individual tx plan will include type and frequency of services. The clinical staff will receive an in-service on clinical documentation by October 30, 2007. The clinical supervisor will audit the tx plans for inclusion of type and frequency of services.
Responsible: Clinical Supervisor-
monthly
Training was done with the Clinical Staff on 9/14/07. The clinical supervisor will insure compliance through monthly chart reviews. |
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 complete treatment plan update in two of four client records reviewed, #2 and 3. Treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
Will moniter TPUD for the next 3 months in CQI. Review of UDTP in supervision and weekly chart audits to include assessment of the clients progress in relationship to the stated goals of the comprehensive tx plan.
Responsible: Clinical Supervisor
12/30/2007 |