INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc., Vantage 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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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of administrative materials, client records and a discussion with the facility director and the clinical supervisor, the facility failed to document a written letter of termination in one of one client record.
The findings include:
Six client records were reviewed on May 13, 2011. Only one of those six client records required a written letter of termination. Client #4 was admitted on 12/4/10 and was therapeutically discharged on 3/24/11. As of 5/13/11, a written letter of termination was not documented in client record #4.
According to the facility's policy on client notification of termination: "Clients shall be advised in writing of the reasons for therapeutic discharge and may discuss reasons with counseling staff. Prior intervention efforts are required and shall be appropriately documented before a Therapeutic Discharge Notice may be given to a client. Exceptions to this policy include significant risk of harm to staff and others. A copy of the Therapeutic Discharge Notice will be maintained in the client record."
During a discussion with the facility director and the clinical supervisor, these findings were confirmed.
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Plan of Correction
Beginning on June 8, 2011 all clients will be provided with the facility's policy on client notification of termination: "Clients shall be advised in writing of the reasons for therapeutic discharge and may discuss reasons with counseling staff. Prior intervention efforts are required and shall be appropriately documented before a Therapeutic Discharge Notice may be given to a client. Exceptions to this policy include significant risk of harm to staff and others. A copy of the Therapeutic Discharge Notice will be maintained in the client record."
Tp prevent a written letter of termination not being sent and in the client record, the counseor will have five days to complete the treatment termination letter and send it to the client and the clinical supervisor will review closed charts within two weeks of discharge to ensure the above policy is upheld.
Person Responsible: Counselor
Person Responsible for Monitoring: Clinical Supervisor
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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 and a discussion with the facility director, the facility failed to keep frozen food at or below 0 degrees Farenheit.
The findings include:
A physical plant inspection was conducted from approximately 10:30AM to 11:30AM. The freezer in the kitchen had a temperature of 13 degrees Farenheit. The digital thermometer was thought to have been incorrect, so the licensing specialist put his thermometer in the freezer and told the facility director he would check the temperature in a little while. The temperature of the freezer in the kitchen was checked again at approximately 1:15PM. The temperature was still at 13 degrees Farenheit.
During a discussion with the facility director, these findings were confirmed.
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Plan of Correction
Based on a physical plant inspection and a discussion with the facility director, the facility failed to keep frozen food at or below 0 degrees Farenheit.
As a result of the freezer in the kitchen not being at or below 0 degrees Farenheit, a work order was put in on May 18, 2011 and the freezer was fixed so that it now maintains a temperature of 0 or below Farenheit. In addition, new thermometers were bought for all the freezers and refrigerators in the facility.
The freezer temperators are checked several times throughout each 24 hour period and the person doing this run will notify the Facility Diretor within 8 hours if the temperature exceeds 0 degrees Farenheit so that a work order can be processed immediately.
Person Responsible: House Manager
Person Responsible for Monitoring: Facility Director
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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 administrative materials, client records and a discussion with the facility director and the clinical supervisor, the facility failed to complete physical examinations within the required time frame as per facility policy in five of six client records.
The findings include:
Six client records were reviewed on May 13, 2011. Physical examinations were required in all six client records. Physicals were completed late, as per facility policy, in five of six client records.
According to the facility's policy titled, PLAN FOR THE COORDINATION OF TREATMENT & REHABILITATION SERVICES: "Upon admission, residents shall have a physical examination performed the first week of admission. The physical examination will assure that a client is free from communicable diseases or any other medically related concern that would pose a significant obstacle to treatment. In cases where a client has received a verifiable physical examination within one month prior to admission, the program Medical Director or his/her designee shall perform an examination comprised of taking and recording of vital signs and asking the client if significant changes have occurred since his/her last exam."
Client #1 was admitted on 12/15/10. The physical documented in client record #1 was dated 1/7/11.
Client #3 was admitted on 11/23/10. The physical documented in client record #3 was dated 12/29/10.
Client #4 was admitted on 12/4/10. The physical documented in client record #4 was dated 1/15/11.
Client #5 was admitted on 10/4/10. The physical documented in client record #5 was dated 10/13/10.
Client #6 was admitted on 11/2/10. The physical documented in client record #6 was dated 11/29/10.
During a discussion with the facility director and the clinical supervisor, these findings were confirmed.
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Plan of Correction
As a result of 5 out of 6 client physicals being late, the following policay will be adhered to.
According to the facility's policy titled, PLAN FOR THE COORDINATION OF TREATMENT & REHABILITATION SERVICES: "Upon admission, residents shall have a physical examination performed the first week of admission. The physical examination will assure that a client is free from communicable diseases or any other medically related concern that would pose a significant obstacle to treatment. In cases where a client has received a verifiable physical examination within one month prior to admission, the program Medical Director or his/her designee shall perform an examination comprised of taking and recording of vital signs and asking the client if significant changes have occurred since his/her last exam."
To ensure that the physicals are done according to the above policy, the nurse will give to the Facility Director within 72 hours of client admission the date of the client's physical in writing. It will be the nurse's responsibility to ensure that physicals are obtained within 7 days of client admission.
Person Responsible: Nurse
Person Responsible for Monitoring: Facility Director
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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 administrative materials, client records and a discussion with the facility director and the clinical supervisor, the facility failed to complete follow-up in one of one client record.
The findings include:
Six client records were reviewed on May 13, 2011. Follow-up was required in three client records. Follow-up was not documented in client record #5.
According to the facility's policy titled, FOLLOW UP INFORMATION: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor ' s designee, to follow-up the discharged client ' s progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
Client #5 was admitted on 10/4/10 and discharged on 3/28/11. As of 5/13/11, follow-up was not documented in the follow up log binder for client #5.
During a discussion with the facility director and the clinical supervisor, these findings were confirmed.
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Plan of Correction
As a result of a review of administrative materials, client records and a discussion with the facility director and the clinical supervisor, the facility failed to complete follow-up in one of one client record.
The following policy will be adhered to.
FOLLOW UP INFORMATION: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor ' s designee, to follow-up the discharged client ' s progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
Client #5 was admitted on 10/4/10 and discharged on 3/28/11. As of 5/13/11, follow-up was not documented in the follow up log binder for client #5.
To ensure that the above policy is adhered to, the intake/aftercare counselor will make the follow-up phone calls within the seven day time period and give in writing a monthly list of discharge clients and the date the followup was done to the Clinical Supervisor.
Person Responsible: Intake/AFtercare Counselor
Person Responsible for Monitoring: Clinical Supervisor/Facility Director
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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 and a discussion with the virtual learning manager and the human resources manager, the facility failed to ensure that each counselor complete at least 25 clock hours of training annually in one of two personnel records.
The findings include:
The facility's training year runs from January to December. The facility's 2010 training year was reviewed for training hours. Seven personnel records were reviewed. Two of those seven staff were counselors and required at least 25 training hours annually.
Personnel record #4 only had documentation of 14 annual training hours for the 2010 facility training year.
During a discussion with the virtual learning manager and the human resources manager, these findings were confirmed.
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Plan of Correction
To ensure that each counselor receives at least 25 clock hours of training annually, The administrative assistant will provide the Facility Director with monthly trainings on all counselors for review and adherence to the above. All trainings for counselors will be scheduled by the Facility Director and Clinical Supervisor.
Person Responsible: Administrative Assistant
Person Responsible for Monitoring: Facility Director/Clinical Supervisor |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records and a discussion with the virtual learning manager and the human resources manager, the facility failed to ensure that each counselor assistant complete at least 30 clock hours of training annually in one of one personnel records.
The findings include:
The facility's training year runs from January to December. The facility's 2010 training year was reviewed for training hours. Seven personnel records were reviewed. Two of those seven staff were counselor assistants. One counselor assistant had not been hired as such until 2011, so training hours were not reviewed for staff #7. Staff #6 is a counselor assistant that was hired in 2009 and required at least 30 hours of annual training.
Personnel record #6 only had documentation of 14.5 annual training hours for the 2010 facility training year.
During a discussion with the virtual learning manager and the human resources manager, these findings were confirmed.
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Plan of Correction
To ensure that each counselor assistant receives at least 40 clock hours of training annually, The administrative assistant will provide the Facility Director with monthly trainings on all counselor assistants for review and adherence to the above. All trainings for counselor assistants will be scheduled by the Facility Director and Clinical Supervisor.
Person Responsible: Administrative Assistant
Person Responsible for Monitoring: Facility Director/Clinical Supervisor
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