INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gratitude House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Reports, the facility failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.The findings include:The Staffing Requirements Facility Summary Reports for the 14 facilities contained within the project were reviewed on October 15, 2013. The equivalent of 105.275 full-time counselors are employed within the project. This would require at least 13 full-time clinical supervisors. The project currently employs 7 full-time clinical supervisors.
|
Plan of Correction
The Vice President of Clinical Services will ensure that the ratio of Clinical Supervisors for the project is within the defined regulation of 1 fulltime clinical supervisor for every 8 fulltime counselors or counselor assistants. The Project will re-evaluate its current system and restructure the project to include the appropriate number of clinical supervisors. Human Resources coordinators will identify the number of clinical supervisors, counselors, and counselor assistants within the system on a quarterly basis. Vice President of Clinical Services will be responsible to review staffing hours quarterly to ensure that ratio is maintained. Program Directors will notify the Vice President of Clinical Services should any changes in the ratio per site occur during the quarter. Restructuring of the Clinical Supervisor ratio will begin December 1, 2013. Clinical Supervisor ratio will be in 100% compliance by January 1, 2014. |
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.
|
Observations
Based on a review of the facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in two of eight records reviewed.The findings include:The facility's SRFSR was reviewed on October 4, 2013. Employee #6, a support staff person, was hired on September 8, 2009. Employee #6 was required to obtain 4 hours of TB/STD the training by September 8, 2011. The training was not documented as of the date of the inspection.Employee # 8, a support staff person, was hired on October 6, 2010. Employee #8 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by October 6, 2012. The training was not documented as of the date of the inspection. The findings were confirmed by the facility director.
|
Plan of Correction
Facility Director will ensure employee #6 will attend the next TB/STD training to be held on 11/7/2013 at Pyramid's Training Center. Facility Director will follow-up with Human Resource Coordinators and employees after said training date to ensure attendance. Human Resource Coordinators will monitor all employee files quarterly to ensure compliance with mandatory training requirements. Employee #8 is no longer employed by Pyramid. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records, staff work schedules and CPR/First Aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR.The findings include:All employee CPR/First Aid certification cards were reviewed on October 8, 2013. There were staff that didn't have training for CPR who worked on various shifts. The facility is open 24 hours Sunday through Saturday. A four week work schedule was reviewed and showed several days where staff worked and there was no CPR coverage.Did not have sufficient coverage on the following days and time: 4pm - 12 am shift (no CPR coverage)August 22, 201312 am - 8 am shift (no CPR coverage)August 24, 2013An interview with the facility director on October 9, 2013, confirmed the findings.
|
Plan of Correction
Facility Director will ensure that all shifts are covered by at least one employee who is CPR/first aid certified. Facility Director and tech supervisor will monitor compliance via obtaining a copy of all employees CPR/first aid cards and comparing these to the staff schedule on a monthly basis. Any employee who is due for CPR/first aid recertification will be reminded by program director and/or tech supervisor to plan to attend the next available training. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one personnel records.The findings include:Fourteen personnel records were reviewed on October 8, 2013. One personnel record pertained to the project director required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.Employee # 1 has been the project director since July 1, 1999. The facility training year is from July through June. Employee # 1 had documentation of 10.5 hours of training for the July 2012 - June 2013 training year.
|
Plan of Correction
Project Manager will complete 12 hours of training annually. Project Manager will ensure needed documentation of completed trainings is presented to Human Resources to be recorded in Personnel File. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
|
Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.The findings include:The fire drill record was reviewed on October 4, 2013. Ten months of fire drills were reviewed. The facility's hours of operation are 24/7. The facility failed to document fire drills between the hours of 11:21 a.m and 7:31 pm. All the drills were documented before 11:21 a.m.
|
Plan of Correction
Facility Director met with maintenance staff on site on 10/21/13 to review fire drill requirements, to include conducting drills during different times of the day on each of the three work shifts. Facility risk committee members and facility director will ensure compliance via reviewing the fire drill log monthly during risk committee meetings. |
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.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client records.The findings include:Ten client records were reviewed on October 9, 2013. Five of the client records reviewed were that of discharged clients. One of the discharged clients was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 10.Client # 10 was admitted into treatment on May 23, 2013 and was involuntarily terminated from the project on August 2, 2013. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on March 9, 2013.An interview with the facility director on March 9, 2013 confirmed the findings.
|
Plan of Correction
Facility Director will conduct an in-service with the counselors by 11/6/13 to review discharge conditions in which a client needs to receive, in writing, the decision to involuntarily terminate the client's treatment. Compliance to this standard will be met via monthly closed chart monitors by the Facility Director. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on the review of client records, the facility failed to ensure clients were informed of the criteria for admission, treatment, completion and discharge in three of ten records reviewed. The findings include: Ten client records were reviewed on October 9, 2013. Eight of the ten records were reviewed from intake to discharge. All records required the client to be notified of the criteria for admission, treatment, completion and discharge upon intake. The facility failed to document notification of the criteria for admission, treatment, completion and discharge in records # 1, 3 and 5.This finding was discussed with the facility director and was not disputed.
|
Plan of Correction
Facility director will conduct an in-service with the clinical staff by 11/06/13 to review the necessity of completing and having in the clinical chart the client history, which is part of the client's psychosocial. This will include the criteria for admission, treatment, completion, and discharge. Compliance will be met via monthly closed and open chart monitors by the facility director. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in one of ten records reviewed. The findings include:Ten client records were reviewed October 9, 2013 Eight of the ten records were reviewed for psychosocial evaluation. The psychosocial evaluations in client records # 1, 4, 5, 6, 7 and 8 did not include an evaluation of the client's assets/strengths and how they would impact treatment. The psychosocial evaluations in client records # 1, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's support systems.The psychosocial evaluations in client records # 1, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment. The psychosocial evaluations in client records # 1, 3, 4, 5, 6, 7 and 8 did not include an evaluation of the negative factors of the client.The psychosocial evaluations in client records # 1 and 4 did not include an evaluation of the counselor conclusions/impressions of the client.
|
Plan of Correction
Facility Director will conduct an in-service with the clinical staff by 11/06/13 to review psychosocial evaluation documentation, to include evaluation of the client's assets/strengths, coping mechanisms, support systems, negative factors towards treatment (to include how all may impact treatment), and the counselor conclusions/impressions of the client. Compliance to this standard will be met via monthly chart monitors of both open and closed charts by the Facility Director. |