INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 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. 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 the personnel records, the facility failed to provide 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 in one out of four employee records reviewed.
Employee #2 was hired on August 15, 2022 as a facility director and was still in the position as of the date of the inspection. The plan dated January 15, 2024, did not have documentation that the supervisor was involved with the development of the plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Director and Program supervisor will develop training plan with new hires in writing along with the training in Relias. Program Director and/or Program Supervisor will have employee sign off on the training plan upon hire and annually. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that one of four employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on October 3, 2022 and was still employed at the time of the inspection. Employee #3 was due to have the communicable disease trainings no later than October 3, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection and the HIV/AIDS training was not completed until January 31, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The employee is no longer with Gaudenzia. Moving forward Program Director will ensure the counselor complete all required DDAP trainings within the first year of hire. Employee will sign off on the training plan and set up quarterly meetings to discuss progress with program director. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility ' s fire drill logs from July 2023 through May 2024, the facility failed to maintain a written fire drill record including the number of persons in the facility at the time of the drill for all drills conducted from July 2023 through May 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Supervisor changed the fire drill sheet to include the number of people in the building at the time of the drill. The new sheet has been utilized. The program supervisor will sign off on the fire drills 3x's monthly to be sure that they are being done correctly. |
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 facility ' s fire drills logs from July 2023 through May 2024, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The new fire alarm sheet has whether will reflect that the actual fire alarm was pulled. Program supervisor will be responsible for calling the fire department to give them the date/time of our alarm, so they do not come out to the facility. In the meantime, PD will work on getting an exception approved by DDAP so that we do not have to pull the fire alarm. The program supervisor will be responsible to ensure plan is followed. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection on May 15, 2024, the facility failed to maintain protective caps over electrical outlets in the common area of the administrative suite, and rooms 201, 204, 211 and 212.
This is a repeat citation from the June 8, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All electrical socket caps have been placed throughout the whole facility and in the bedrooms. Staff was also reminded to check if caps need to be replaced during hourly runs. Program Supervisor will do weekly checks to be sure the caps are over all the sockets. Program Director will complete monthly checks. |
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 three applicable 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 #2 was hired on August 15, 2022 as the facility director and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 16, 2024.
Employee #3 was hired on October 3, 2022 as a counselor and was still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 21, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will ensure all staff sign their evaluation annually by February 1st. Program Director will be responsible to ensure all Hutchinson Place staff sign their Evaluations on time. Regional Director will be responsible to ensure that Program Director will sign his/her evaluation on time. |
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 #4 was admitted on July 10, 2023 and discharged on April 20, 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
Program Director went over having all consents signed with admission staff and counselors. Program director will train admin to complete weekly audits of charts to make sure are consents are completed upon admission. |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a physical plant inspection of the drug storage area on May 15, 2024, the facility failed to include only medications in the refrigerator of the drug storage area. A non-medication item, such a coffee creamer and food, were also contained in the refrigerator at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Non-medical items were removed on the day of inspection, and staff refrigerator was purchased. Nursing was notified not to allow any staff to put non-medical food in the medication refrigerator. Program director sent email to the staff to inform them not to utilize the nursing refrigerator for personal items. Nursing staff is responsible to make sure the medication refrigerator only has medication in it. |
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 May 15, 2024, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there was topical cream 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
Nursing will be responsible to make sure once residents use their creams the staff put them back in the correct drawer. An email was sent out to staff to make sure the topical and cream medications are kept separate. This will also be added to meeting topics quarterly as reminders. Nursing staff will be responsible to make sure all medications are in the correct place. |
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 the review of client records, the facility failed to document a complete psychosocial evaluation per the facility ' s policy and procedures manual in three out of seven records. The facility ' s policy states a psychosocial evaluation is completed within five days of admission.
Client #2 was admitted on January 30, 2024 and was still active at the time of the inspection. A psychosocial evaluation was due no later than February 4, 2024; however, it was not completed until February 9, 2024.
Client #4 was admitted on July 10, 2023 and discharged April 20, 2024. A psychosocial evaluation was due no later than July 15, 2023; however, there was no documentation that a psychosocial evaluation was completed.
Client #7 was admitted on July 28, 2023 and discharged on December 27, 2023. A psychosocial evaluation was due no later than August 2, 2023; however, it was not completed until August 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During that time Hutchinson Place did not have a nurse to oversee the evaluations were being completed on time. Program Director will have supervision with counseling staff to keep track of biopsychosocial being completed within 5-days of admission. Program Director will do weekly audits to ensure they are completed on time. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the timeframe established by the facility ' s policy and procedures in three out of seven records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed within five days of admission.
Client #2 was admitted on January 30, 2024 and was still active at the time of the inspection. The preliminary treatment plan was due no later than February 4, 2024; however, it was not completed until February 14, 2024.
Client #6 was admitted on August 17, 2023 and discharged on January 8, 2024. The preliminary treatment plan was due no later than August 22, 2023; however, it was completed on Augst 23, 2023.
Client #7 was admitted on July 28, 2023 and discharged on December 27, 2023. The preliminary treatment plan was due no later than August 2, 2023; however, it was not completed until August 9, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will complete weekly Clinical Scorecard audits to make sure Tx. plans are completed on time by counseling staff and the deficiency does not occur again. Program director will have supervision with counseling staff about completing treatment plans in a 5-day time period then every in a 30-day thereafter. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to complete an individual treatment and rehabilitation plan developed with the client within the regulatory timeframe in seven out of seven records reviewed. The facility ' s policy and procedures manual states that the comprehensive treatment plan will be developed with the client within thirty days of admission.
Client # 1 was admitted on December 28, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due no later than January 28, 2024; however, it was not completed until February 13, 2024.
Client #2 was admitted on January 30, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due no later than March 1, 2024; however, it was not completed until March 11, 2024.
Client #3 was admitted on November 30, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due no later than December 30, 2023; however, it was not completed until January 2, 2024.
Client #4 was admitted on July 10, 2023 and was discharged on April 20, 2024. The individual treatment and rehabilitation plan was due no later than August 10, 2023; however, it was not completed until September 22, 2023.
Client # 5 was admitted on November 30, 2023 and was discharged on May 3, 2024. The individual treatment and rehabilitation plan was due no later than December 30, 2023; however, it was not completed until January 3, 2024.
Client #6 was admitted on August 17, 2023 and discharged on January 8, 2024. The individual treatment and rehabilitation plan was due no later than September 17, 2023; however, it was not completed until December 1, 2023.
Client #7 was admitted on July 28, 2023 and was discharged on December 27, 2023. The individual treatment and rehabilitation plan was due no later than August 28, 2023; however, it was not completed until September 12, 2023.
This is a repeat citation from the June 8, 2023 licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director went over findings with counselor. Program director will complete weekly audits to ensure comprehensive treatment plans are done every 30-days. |
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 per regulatory requirements of every thirty days in four out of seven applicable records reviewed.
Client #1 was admitted on December 28, 2023 and was still active at the time of the inspection. A treatment plan was completed on February 13, 2024, and the next update was due no later than March 13, 2024; however, it was not completed until March 21, 2024.
Client #2 was admitted on January 30, 2024 and was still active at the time of the inspection. A treatment plan was completed on April 12, 2024, and the next update was due no later than May 12, 2024; however, there was no documentation that one was completed.
Client #3 was admitted to on November 30, 2023 and was still active at the time of the inspection. A treatment plan was completed on February 29, 2024, and the next update was due no later than March 29, 2024; however, it was not completed until April 12, 2024.
Client #4 was admitted to on July 10, 2023 and discharged on April 20, 2024. A treatment plan was completed on February 3, 2024, and the next update was due no later than March 3, 2024; however, it was not completed until March 21, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director went over findings with the counselor. Program director will run weekly reports to be sure documents are being completed every 30-days. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in four out of seven records reviewed.
Client #1 was admitted on December 28, 2023 and was still active at the time of the inspection. A treatment plan dated February 13, 2024, indicated individual counseling one time per week. There was no documentation that the client received individual counseling the weeks of February 19 and 26, 2024.
Client #2 was admitted on January 30, 2024 and was still active at the time of the inspection. The treatment plan dated March 11, 2024, indicated individual counseling one time per week. There was no documentation that the client received individual counseling the week of March 18, 2024.
Client #4 was admitted on July 10, 2023 and discharged on April 20, 2024. The treatment plans dated November 11, 2023, and December 4, 2023, indicated individual counseling one time per week. There was no documentation that the client received individual counseling in December 2023.
Client #7 was admitted on July 28, 2023 and was discharged on December 27, 2023. The treatment plans dated September 12, 2023, October 12, 2023, November 7, 2023, and December 12, 2023 indicated individual counseling one time per week. There was no documentation that the client received individual counseling the weeks of September 4, 25, October 23, 30, November 20, 27 and December 4, and 18, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director spoke with counselor. When a resident misses a session, please complete a note indicating why. If the resident dies not need weekly session, please indicate that in the treatment plan with clinical rationale. Program director will complete weekly chart audits of individual sessions being completed for all residents. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the timeframe established by the facility ' s policy and procedure manual in five out of seven records reviewed. The facility's policy and procedures manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety then one is completed.
Client #1 was admitted on December 28, 2023 and was still active at the time of the inspection. A case consultation was completed on January 23, 2024, and the next one was due no later than April 23, 2024; however, there is no documentation that one was completed.
Client #4 was admitted on July 10, 2023 and discharged on April 20, 2024. A case consultation occurred on September 13, 2023, and the next one was due no later than December 13, 2023; however there is no documentation that one was completed.
Client #5 was admitted on November 30, 2023 and discharged on May 3, 2024. A case consultation was completed on January 12, 2024, and the next one was due no later than April 12, 2024; however, there is no documentation that one was completed.
Client #6 was admitted on August 17, 2023 and discharged on January 8, 2024. A case consultation was due no later than November 17, 2023; however, it was not completed until December 1, 2023.
Client #7 was admitted on July 28, 2023 and was discharged on December 27, 2023. A case consultation was completed on September 5, 2023, and the next update was due no later than December 5, 2023; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will hold bi-weekly case consults with nursing, clinical, and administration to avoid missing case consultation dates. Program director will ensure plan of correction is followed. |
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, the facility failed to provide a complete client record, which is to include follow-up information in two out of two applicable discharged records reviewed. The facility ' s policy and procedures manual states that follow ups are to be completed within 7 days of aftercare appointment or within thirty days of discharge.
Client #6 was admitted on August 17, 2023 and was discharged on January 8, 2024. A follow up was due no later than February 8, 2024; however, there is no documentation that one was completed.
Client #7 was admitted on July 28, 2023 and discharged on December 27, 2023. A follow up was due no later than January 27, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director had a meeting with counselors about follow-up and documentation being completed in 7days after aftercare appointment or 30-days of discharge. Program director will do discharge reviews monthly to ensure follow-ups are being completed. |