INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26-27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on June 24, 2009.
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to document a written semiannual performance evaluation in one of one personnel record.
Findings:
Six personnel records were reviewed on May 27, 2009. A semiannual performance evaluation was required in one personnel record. The facility did not document a semiannual performance evaluation for the counselor assistant represented by personnel record #6.
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Plan of Correction
4010: Supervision of Staff page # 52 of the Gaudenzia Personnel Manual:
The Program supervisor will conduct a semi annual on the performance of the Counselor Assistant.
The Program Director will monitor the timeline to ensure that the Semi Annual Job Performance Evaluation is completed and reviewed on each Counselor Assistant as needed.
The Administrative Coordinator will conduct audits on all personnel charts to ensure performance evaluations are completed within the time frame of the standards.
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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 personnel records, the facility failed to document direct observation and close supervision in one of one personnel record.
Findings:
Six personnel records were reviewed on May 27, 2009. The facility did not document direct observation supervision notes for the first three months of employment, and close supervision notes for the next nine months of employment for the counselor assistant represented by personnel record #6.
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Plan of Correction
The Program Supervisor will follow the policy and document observation of the counselor assistant's clinical performance for the first three months. The Program Supervisor will document the performance for the remaining 9 months, conduct weekly close supervisions for on all Counselor Assistants employed at Broad Street. |
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 a written individual training plan in five of six personnel records.
Findings:
Six personnel records were reviewed on May 27, 2009. Individual training plans were required in six personnel record. The facility not document an individual training plan by January 31, as stated in the project's policy manual, in personnel records # 2, 3, 4, 5 and 6.
Personnel record #2- training plan documented 5/5/09
Personnel record #3- training plan documented 3/24/09
Personnel record #4- training plan documented 5/1/09
Personnel record #5- training plan documented 5/4/09
Personnel record #6- training plan documented 5/4/09
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Plan of Correction
4030: Staff Training, Gaudenzia personnel Manual page # 55.
Training Needs Assessment & Plan Form:
The Program Supervisors and the Director will have each staff person complete their written training plan in the second week of January of each year during the staff meeting. The Director will review all plans to develop the overall needs of the facility. The Administrative Coordinator, Program Supervisors and the Director are responsible for the oversight.
The Director will give the training plans to the Divisional Director for input and approval according to the policy.
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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, the facility failed to document a minimum of 6 hours of HIV/AIDS training in one of six personnel records.
Findings:
Six personnel records were reviewed on May 27, 2009. Six hours of HIV/AIDS training was required in six personnel records. The facility did not document 6 hours of HIV/AIDS training in personnel record # 6.
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Plan of Correction
The supervisors will review, with the director the DOH policy on 6 hours HIV/AIDS and the 4 hours TB training requirement using a Department approved curriculum. The supervisor's unit unique will reflect his/her job responsibility of ensuring timely scheduling of said trainings.
A newly developed computer generated file will notify the administrator coordinator when trainings are due.
Staff person #6 will attend 6 hours of HIV/AIDS training.
The Program Supervisor will complete a training request form and schedule the HIV/AIDS training with the Training Institute.
The Administrative will submit and obtain a confirmation for the training for staff member # 6.
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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 personnel records, the facility failed to document a minimum of 25 hours of training in one of one personnel record.
Findings:
Six personnel records were reviewed on May 27, 2009. Twenty-five hours of training was required in one personnel record. The facility did not document 25 hours of training for the 2008 training year in personnel record # 5.
Personnel record #5 documented 10 hours of training for the 2008 training year.
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Plan of Correction
The Administrative Coordinator's newly developed computer generated file will notify the administrator coordinator when trainings are due. The Administrative Coordinator will schedule the trainings in accordance to the policy. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to store all eating utensils in a clean enclosed area when not in use.
Findings:
A physical plant inspection was conducted on May 27, 2009 at approximately 13:30. The facility was required to store eating utensils in an enclosed area. The forks, knives and spoons were stored in an uncovered utensil tray on a counter in the dining area.
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Plan of Correction
The Operational Program Supervisor met with the Cook to discuss the policy and procedure for the storing of the utensils.
The plan is to cover the utensil canister after each meal to avoid contaminates and to keep the utensils clean. The operations program supervisor will be responsible to ensure the procedure is carried out.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to maintain cold food at or below 40 and frozen food at or below 0 physical plant inspection was conducted on May 27, 2009 at approximately 13:30. The temperature of the freezer in the basement was 30 and the temperature of the refrigerator in the basement was 44 These temperatures were rechecked at 16:00 but remained unchanged.
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Plan of Correction
Operational Program Supervisor contacted the service repairman on 5/27/09 to report the problem. American Kitchen arrived on 5/27/09. They detected the problem but was unable to repair the motor on the freezer. A repairman from Service Court arrived on site and inspected the freezer. The freezer could not be repaired the same day. Service parts for the motor were ordered and the freezer is now operational and up to code. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways are unobstructed at all times.
Findings:
A physical plant inspection was conducted on May 27, 2009 at approximately 13:30. An interior stairway exit on the second floor was obstructed by equipment left behind from recent repair work, and an interior stairway exit on the third floor was obstructed by a ladder.
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Plan of Correction
The Operational Program Supervisor instructed the Housemanager to remove the ladder and other materials from the stairway on the 2nd and 3rd floors.
The Housemanagers will ensure that the stairways and all other areas are cleared for safety at all times.This will occur during the Fire and Saftey Runs conducted every hour throught the facility . The run and any findings are documented in the communication log book which is reviewed by each staff on all shifts.
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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. 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, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in four of four client records.
Findings:
Seven client records were reviewed on May 27, 2009. Documentation of informed and voluntary consent was reviewed in four records. The facility documented the release of specific client information that exceeds the limitations imposed at 4 Pa Code subsection 255.5(b) in client records # 1, 2, 3 and 4.
Client record # 1, 2, 3 and 4 documented the release of " Scheduled treatment goals and the achievement of treatment goals " to a government agency.
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Plan of Correction
According to the policy on Confidentiality and Relationships with Healthcare Partners, the clients will have their rights to confidentiality and privacy upheld.
The Clinical Program and Operational Supervisors will provide a review with all staff on each shift, of what can be divulged to healthcare providers.
The Program Director will train staff to not discuss or release client information with others unless it is the five items only to the third party payers or government agencies even with the clients consent.
These disclosures will be made in the compliance with the state and federal confidentiality laws and
regulations.
The Program Supervisor will conduct random audits of the release forms to maintain compliance.
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709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug and alcohol history in two of four client records.
Findings:
Seven client records were reviewed on May 27, 2009. Drug and alcohol histories were reviewed in four client records. The facility failed to document a drug and alcohol history within 72 hours after admission, as stated in the facility's policy manual, in client records # 1 and 3.
Client record #1- admission date 1/6/09, but drug and alcohol history documented 1/14/09.
Client record #3- admission date 1/15/09, but drug and alcohol history documented 1/22/09.
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Plan of Correction
The Divisional Director during supervision will provide an in-service training to the Recovery Specialist to review the procedures of obtaining documentation of the Drug and Alcohol history of each client during the intake process.
The Clinical Program Supervisor will conduct an in service with the Counselors on gathering the Drug and Alcohol history within the seventy two hour period according to policy.
On Saturdays the Clinical Program Supervisor will conduct random audits on the clinical charts for timeliness and completeness of documentation during the intake and admission process.
Written findings of the audit will be given to the Director each Wednesday during the management meeting for review and to ensure compliance
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history in two of four client records.
Findings:
Seven client records were reviewed on May 27, 2009. Personal histories were reviewed in four client records. The facility failed to document a personal history within 72 hours after admission, as stated in the facility's policy manual, in client records # 1 and 3.
Client record # 1- admission date 1/6/09, but personal history documented 1/14/09.
Client record # 3- admission date 1/15/09, but personal history documented 1/22/09.
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Plan of Correction
The Clinical Program Supervisor will conduct an in service with the Counselors on gathering the client's personal history within the seventy two hour period according to policy.
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The Clinical Program Supervisor will conduct weekly audits addressing the timeliness and completeness of the personal history.
The Program Supervisor will conduct chart audits of the program supervisor to ensure the thoroughness and completeness of the clinical charts (audits).
The Director will review the audits with the Program Supervisor to ensure the personal history is documented within the seventy two hour after admission.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination in four of four client records.
Findings:
Seven client records were reviewed on May 27, 2009. Physical examinations were reviewed in four client records. The facility failed to document a physical examination within 48 hours after admission, as stated in the facility's policy manual, in client records # 1 2, 3 and 4.
Client record # 1- admission date 1/6/09, but physical exam documented 1/9/09.
Client record # 2- admission date 2/20/09, but physical exam documented 2/25/09.
Client record # 3- admission date 1/15/09, but physical exam documented 1/30/09.
Client record # 4- admission date 3/17/09, but physical exam documented 4/1/09.
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Plan of Correction
The Program Director met with the physician regarding the lateness of the physicals. A review of the policy was discussed.
The Health Service staff will contact the physician by telephone prior to admission to ensure the physical is completed in a timely fashion according to the policy.
In addition, a physical alert system was developed by Broad Street nursing staff to schedule client physicals examinations in a timely manner to ensure compliance.
The Health Service staff and the Program Director will conduct medical chart audits to ensure the physicals are completed within the appropriate time frame.
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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 psychosocial evaluation in four of four client records.
Findings:
Seven client records were reviewed on May 27, 2009. Psychosocial evaluations were reviewed in four client records. The facility failed to document a psychosocial evaluation within 72 hours after admission, as stated in the facility's policy manual, in client records # 1, 2, 3 and 4.
Client record # 1- admission date 1/6/09, but psychosocial evaluation not dated.
Client record # 2- admission date 2/20/09, but psychosocial evaluation not dated.
Client record # 3- admission date 1/15/09, but psychosocial evaluation documented 1/22/09.
Client record # 4- admission date 3/17/09, but psychosocial evaluation not dated.
Additionally:
Client records # 3 and 4 did not document a psychosocial evaluation to include the client's assets, strengths or other factors that can contribute to the resolution of identified problems.
Client records # 3 and 4 did not document a psychosocial evaluation to include the potential or available client support systems.
Client records # 1, 3 and 4 did not document a psychosocial evaluation to include the client's preferred coping mechanisms.
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Plan of Correction
An in-service review will be conducted on completing the documentation of psychosocial evaluations. An emphasis will be placed on providing signatures and dates on all documents.
The Social Worker and Program Supervisors will complete the Psychosocial evaluation within the seventy two hour time frame when the Counselors are unable to complete the psychosocial within the seventy two hour guidelines.
The Clinical Program Supervisor will audit the clinical charts and give a written review to the Program Director each Wednesday. The chart audit will address the timeliness, completeness and effectiveness of the psychosocial evaluations.
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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 a treatment plan to include type and frequency of treatment and rehabilitation services in four of four client records.
Findings:
Seven client records were reviewed on May 27, 2009. Treatment plans were required to include type and frequency of treatment and rehabilitation services in four client records. The facility did not document type and frequency of treatment and rehabilitation in client records # 1, 2, 3 and 4.
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Plan of Correction
All staff had attended several clinical documentation trainings. The clinical program supervisor was given disciplinary action for not being complete in her chart audits of the clinical staff. The clinical staff, having already reviewed the policy, and having attended several trainings and in-services, received disciplinary action addressing their inconsistency in adhering to the policy. The Program supervisor will conduct weekly audits addressing the type and frequency of treatment and rehabilitation. The program director will conduct chart audits of the program supervisor to ensure the thoroughness and completeness of her work (audits). |
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 treatment plan update in three of four client records.
Findings:
Seven client records were reviewed on May 27, 2009. Treatment plan updates were reviewed in four client records. The facility did not document a treatment plan update to include an assessment of the clients' progress in relationship to the stated goals of the comprehensive treatment plan in client records # 2, 3 and 4.
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Plan of Correction
All treatment plan updates will be reviewed on a weekly basis by the Program Director during the treatment team.
The Clinical supervisor will develop a monthly tracking form to monitor the treatment regime and to ensure that the treatment plan updates is within the time frame of 30 days or less.
Clinical Program Supervisor will conduct an in-service with the counselor's on what constitutes an assessment of the client's progress in relation to stated goals.
The Director will conduct random audits of the charts during the treatment team to ensure compliance
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