INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25 - 26, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Kindred 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report presented to the Licensing Specialist at the time of the licensing inspection, the facility failed to document the qualifications and training of staff.
The findings include:
On May 25, 2011, the Staffing Requirements Facility Summary Report completed by the Facility Director, was presented to the Licensing Specialist. The form lacked the following information:
Page #2 lacked the number of hours and the provider for the HIV/AIDS & TB/STD training.
Page # 3 lacked documentation regarding the institution from which the degree was conferred for employee #3 and lacked the name of the institution from which the degree was conferred and the major course of study for employee #4
Page #3 lacked documentation of the number of years experience that employees # 4 & 5 had for Drug and Alcohol Direct Service and the number of years of experience employees #4 & 5 had relating to non-Drug and Alcohol Clinical experience.
Page #4 lacked documentation of the number of hours of training and who provided the training for the HIV/AIDS and TB/STD trainings for emplouyees # 4 & 5.
Page #4 lacked documentation of the number of hours of training and who provided the training for the TB/STD trainings for employees #11.
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Plan of Correction
The Staffing Requirements Facility summary Report will be maintained and completed in its entirety yearly by the administrative assistant who will update form with any new data.
Form will be reviewed by Program Director prior to submission to the training manager who will review form prior to submission to the licensing specialist |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the Staffing Requirements Facility Summary Report (SRFSR) completed by the Facility Director on 5/25/2011 and an interview with the Facility Director, the facility failed to ensure that each staff person identified as providing counseling services met the qualifications for the position in one of three personnel records reviewed.
The findings include:
On May 25, 2011, the Staffing Requirements Facility Summary Report completed by the facility was reviewed. On page five of the SRFSR, the facility identified employees # 3, 4, 5 & 11 as staff who were providing counseling services to the clients. Employee # 5 was identified as a Counselor Assistant and employees # 3, 4, and 11 were all identified as counselors. Employee #11 was not identified as a Counselor on page four of the SRFSR, but was listed as a support staff person on page 7 of the SRFSR having the job title of an "Intake/Aftercare Specialist".
This discrepancy was brought to the attention of the Facility Director on May 25, 2011. The Facility Director stated that employee #11 counseled clients from time to time and that the employee's position was somewhere between that of a Counselor and a Clinical Supervisor.
A review of employee # 11's personnel record revealed that the employee did not meet the experiential requirements for the position of Counselor. The employee, having received an Associates Degree in Addiction Studies in 2009, lacked documentation verifying the completion of two years (a minimum of 3,640 hours) of clinical experience in a health or human service agency.
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Plan of Correction
Counselor number 11 is currently enrolled in Lincoln University Master's degree program. She has already completed 1 year of her degree and only has seven months to Graduate.
No staff person/specialist will be able to counselor clients that do not meet BDAP regulations.
Counselors will meet BDAP requirements as well as Gaudenzia's to assure that the counselor is qualified to counselor clients prior to counseling any clients.
Counselor # 11 will have and addendum added to her job description July 12, 2011 to include her working in the capacity of a counselor assistant III and will be supervised by the program supervisor.
Program director will review all resumes after the Program supervisor has identifies a possible candidate for the position of counselor to assure they met BDAP requirements prior to hire.
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of personnel records, supervisory notes and a conversation with the Facility Director, the facility failed to ensure that a full-time clinical supervisor or counselor meeting the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor) was providing supervision of employee #5, a Counselor Assistant.
The findings include:
On May 25, 2011 the Staffing Requirements Facility Summary Report (SRFSR) completed by the Facility Director on May 25, 2011 was reviewed.
Employee #5 was identified on the SRFSR as a Counselor Assistant having a hire date into that position on January 1, 2011. When questioned about the supervision and supervisory notes for employee #3, the Facility Director explained that they were providing the supervision of employee #3 and provided documentation of supervisory notes.
Employee #2 was identified as the Facility Director having a DD, Master of Science Degree with no listed major. Based upon a review of Employee #2's personnel record they do not meet the requirements of 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor). Employee #2's only documented degree in the personnel record was for a BA in Organizational Management. While this meets the requirements for the position of Facility Director, it does not meet the requirements for the position of Clinical Supervisor or Counselor.
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Plan of Correction
Employee #2 has an Associate of Applied Science degree in Human Service from Montgomery County Community College and an Associate of the Arts degree in Social Science from Montgomery County Community College. In addition employee # 2 has a Bachelors of Arts degree in Organizational Management from Cabrini College along with a Master's of Science degree from Eastern University. Copies of of employee #2 diplomas and transcripts are on file at the corporate office in Norristown.
An official transcript will be ordered 7/13/2011 from Montgomery County Community College after obtained then it will be submitted Gaudenzia Corp HR office so they then first make verification then submit to the Department.
All degrees and verification will be verified at the corporate level prior to hiring employee.
7/29/2011 |
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 the employee personnel record, the facility failed to document the required period of direct observation for one counselor assistant.
The findings include:
Ten personnel records were reviewed on May 10, 2011. One of the ten personnel records reviewed were for the position of counselor assistant. The counselor assistant represented in record # 5, was hired on February 1, 2010 and promoted to the position of counselor assistant on January 1, 2011. There was no verification that a degree had been conferred for employee #5 and therefore the employee is required to have three months of documented direct observation and nine months of close supervision. As of the date of inspection there was no documented verification that employee # 5 had the required supervision for the first three months in the position of counselor assistant.
The lack of documentation was confirmed by the Facility Director on May 26, 2011.
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Plan of Correction
Employee # 5 has contacted Wilkes Barrie University to obtain proof that she has completed all course work required of her BA degree in Psychology and that her degree is conferred.
Becuse she could not verify proof of her degree she will be transferred to another program in a differant position as of July 29, 2011.
All employees seeking employment at Kindred House will not be hired until the HR department has received verification that the employee has the degree they indicated.
This will be done by HR department actually seeing the official transcript and the confering degree employee states they have obtained. Once approved HR will contact Kindred House Administrative Assistant then the employee can be hired. |
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 ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
On May 26, 2010 one personnel record were reviewed. The facility failed to document the required training hours in one of one personnel record.
Employee #11 was hired on August 14, 2006, HIV/AIDS training was due by August 14, 2008. As of the date of the licensing inspection, there was no documentation of this training. Employee #11's record had not been reviewed during previous inspections as they only became mandatory to review during this inspection.
An interview was held with the Facility Director and employee #11 in which they could not provide verification that the 6 hours of HIV/AIDS training was taken.
This is a repeat citation.
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Plan of Correction
Employee #11 Will attend required HIV/AIDS training By July 29, 2011.
Program director will make sure that all new staff attend required training in alloted time frame by scheduling training as soon as a employee has been hired.
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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 training records, the Staffing Requirements Facility Summary Report, and a discussion with Training Manager and the Facility Director, the facility failed to ensure that each counselor receive at least 25 clock hours of training annually in one of two personnel records
The findings include:
On May 10, 2011, personnel and training records for two counselors were reviewed to ensure that the facility documented the required 25 clock hours of training for the 2010 training year. According to the Staffing Requirements Facility Summary Report, the facility training year runs from January 1, 2010 to December 31, 2010. The facility failed to ensure employee #3 had 25 training hours for the 2010 training year.
Employee # 3 was hired as a counselor on February 27, 2000. Employee # 3 had only 6 documented clock hours of training during the January 1, 2010 through December 31, 2010 training year.
On May 10, 2011 an interview was held with the Training Manager in which an inquiry was made if employee #3 had any additional documentation of training hours for the 2010 training year, the inspector was advised there was no additional documentation for employee # 3. On May 25, 2011 an interview was held with the Facility Director in which the same inquiry was made, and it was confirmed there was no further documentation of training hours for employee #3.
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Plan of Correction
Employee # 3 is currently scheduled for trainings and she has been attending trainings to make sure that she has the required number of annual trainings as required to meet the standard. Program director and Program Supervisor will make sure employee # 3 attends trainings as scheduled and required.
Employee will receive annual training plan in Jan of each year. Training hours of at least 25 will be indicated by name of training and date of training for that year.
The employee will sign off on the plan and will be given a copy.
The administrative assistant will receive a copy and give employee a reminder so that the employee will not miss a scheduled training.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observations on May 26, 2011 the facility failed to ensure that the water temperature did not exceed 120 F in 7 of 8 client bedrooms reviewed.
The findings include:
The physical plant inspection was conducted on May 26, 2011 at 1:30pm. During the tour temperatures were taken in each of the eight client bathrooms, seven of those measured above 120 degrees.
1. The bathroom in bedroom # 1 water temperature was 125 F.
2. The bathroom in bedroom # 2 water temperature was 130 F.
3. The bathroom in bedroom # 4 water temperature was 129 F.
4. The bathroom in bedroom # 5 water temperature was 131 F.
5. The bathroom in bedroom # 6 water temperature was 134 F.
6. The bathroom in bedroom # 7 water temperature was 136 F.
7. The bathroom in bedroom # 8 water temperature was 140 F.
The Facility Director and Maintenance Director were both present during the tour and confirmed the temperatures.
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Plan of Correction
1. The House Manager Supervisor will check the temperature of the bathroom water in all eight rooms on a weekly basis.
2. A chart will developed to track water temperature to assure that the temperature is at 120 degree and not above to assure the safety of the clients.
3. If water temperature is above 120 F at any time the Property Manager will be contacted to turn the temperature on the hot water heater to obtain a temperature of 120 degrees.
When the water temperature was higher than 120 degrees the property manager was contacted and he came to Kindred House and turned the thermostat down on the hot water heater so the temperate did not exceed 120 degrees. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records and an interview with the Training Manager, the facility failed to document that fire extinguisher training was provided upon employment in six of six personnel records reviewed.
The findings include:
On May 10, 2011, six personnel records were review for documentation that fire extinguisher training was provided upon employment. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 2, 6, 7, 8, 9, and 10.
Personnel # 2 was hired on 2/3/2011, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 6 was hired on 8/2/2010, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 7 was hired on 8/16/2010, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 8 was hired on 3/28/2011, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 9 was hired on 10/19/2009, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 10 was hired on 7/13/2009, but the training certificate indicated this training occurred on 5/19/2011.
During an interview the Training Manager confirmed there was no prior documentation of fire extinguisher training for employees #2, 6, 7, 8, 9, and 10.
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Plan of Correction
House Manager Supervisor is now required to provide fire extinguisher training to all new staffed hired
**within seven days of their hire date.
House Manger Supervisor will be notified of all new employees' start dates.
House Manger Supervisor will give a date and time the training will be done to the Program Director making sure that the training occurs within the seven day time frame.
Program Director will check to make sure training is completed on that
date.
After training is completed each staff shall receive a certificate indicating that training was completed with date that training was completed then it will be placed in individual personnel file on site and a copy will be sent to the corporate office.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document fire drills at least once a month in the last year.
The findings include:
The fire drill record log was reviewed on May 26, 2011. The log was reviewed from the time period covering June 2010 through May 2011. There was no documentation that a fire drill had been conducted for one of those months reviewed. A fire drill had not been conducted for February 2011. All other months were documented.
This was confirmed with the facility director.
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Plan of Correction
House Manager Supervisor has assigned the night house manager to conduct fire drills as mandated so that Kindred House will be in compliance with BDAP regulations.
The house manager supervisor will also be responsible to assure the drills are competed monthly as scheduled.
Director will also check the fire drill log to assure the drills are being completed on a monthly basis as required.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records and an interview with the Training Manager, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in six of six personnel records reviewed.
The findings include:
On May 10, 2011, six personnel records were review for documentation that all personnel on all shifts had been trained trained to perform assigned tasks during emergencies. The facility did not document that all personnel on all shifts had been trained to perform assigned tasks during emergencies in six of six personnel records reviewed, specifically, records # 2, 6, 7, 8, 9, and 10.
Personnel # 2 was hired on 2/3/2011, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 6 was hired on 8/2/2010, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 7 was hired on 8/16/2010, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 8 was hired on 3/28/2011, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 9 was hired on 10/19/2009, but the training certificate indicated this training occurred on 5/19/2011.
Personnel # 10 was hired on 7/13/2009, but the training certificate indicated this training occurred on 5/19/2011.
During an interview the Training Manager confirmed there was no prior documentation of emergency training for employees #2, 6, 7, 8, 9, and 10.
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Plan of Correction
All new staff will receive training on dealing with emergency situations and evacuation procedures
***within 7 days of hire.
The house manager supervisor is now responsible to assure that this happens in within the allotted time frame of seven days.
House manager supervisior will complete the training and provide a certificate with date of training being completed and send one copy to corporate office in Norristown and place one copy in file at facility.
Director will supervisor house manger supervisor to assure this is done in a timely fashion.
House Manager Supervisor will be made aware of all new employees' hire date.
House manager Supervisor will set a date and time for training to be completed within time frame of 7 days.
She will give date and time to Program Director and she will assure that training is completed as scheduled within seven day time frame..
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709.26(d)(3) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(3) The verification of training experience and professional licensure or registration, where applicable.
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Observations
Based upon a review employee #11's personnel record and the most current job description signed on 11/10/08 by employee #11 for the position of "Specialist II", the facility failed to verify the employee met the training experience required for the position.
The findings include:
Employee #11 was promoted to the position of "Specialist II" on 11/10/2008 and signe d the job description for the position. The job description lists the minimum requirements as follows:
"Minimum Requirements:
1. Education and Training: Bachelors degree in a generally recognized clinical discipline plus s specialized [sic] p opulation [sic]; a nd [sic]/or full certification a s [sic] an Addictions Counselor o r[sic] c ertification[sic] a s [sic] an Addictions Counselor or certification in a spceiality area; or Masters Degree in related speciality area.
2. Experience: Three (3) years of D&A counseling, prevention, or educational experience which included at least two years in speciality area.
3. Sobriety: If recovering, two (2) years sobriety.
4. Substitutions: Appropriate substitions may be made for any equivalent combination of experience, education, and training (1 year experience = 1 year education and traininig."
The listed duties and responsibilities for the position lists providing individual and group sessions for the target population.
The degree in employee # 11's personnel record was for an AA in Addictions Counseling obtained in 2009.
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Plan of Correction
Employee # 11 paper work in her employee file at Kindred House has her listed as a Intake/After Care Specialist II, however when I checked with the HR at the Corporate level she is on the rooster as a Intake/Aftercare Specialist I. The paper work is incorrect in her file.
Upon further review of # 11 personnel file Specialist I and II was in the file. The promotion never took place.
Job description for Specialist II was removed from #11 employee file.
In the further more careful review of personnel files will be conducted by Administrative Assistant who is responsible for filing.
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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 and the facility's policy and procedure manual, the facility failed to document physical examinations in accordance to the project's policies and procedures in five out of seven client records.
The findings include:
On May 26, 2011 seven client records were reviewed for a physical examination. The facility neglected to record the physician's impressions in the physical examination in four client records, # 2, 3, 6, and 8, additionally, the physical exam was documented late in client record #6. One client record, #7 did not have documentation of a physical exam at all.
The facility policy titled; PHYSICAL EXAMINATION LABORATORY STUDIES states:
A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend.
Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client.
Client # 2 was admitted on January 6, 2011, the physical examination was completed on January 10, 2011 and did not include documentation of the physician's overall impression of the client.
Client # 3 was admitted on November 6, 2011, the physical examination was completed on November 16, 2010 and did not include documentation of the physician's overall impression of the client.
Client # 6 was admitted on January 21, 2010, the physical examination was due by February 1, 2011 but was completed on February 4, 2011 and did not include documentation of the physician's overall impression of the client.
Client # 7 was admitted on April 21, 2011, the physical examination was due to be completed by May 2, 2011 and had not been documented as of the date of inspection.
Client # 8 was admitted on March 10, 2011, the physical examination was completed on March 11, 2011 and did not include documentation of the physician's overall impression of the client.
A conversation was held with the Facility Director on May 26, 2011 in which the lack of documentation of the physician's impressions was confirmed.
This is a repeat citation.
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Plan of Correction
The RN spoke with the Dr. who currently does the exams on the women (that are not pregnant) on 5/9/2011 who stated that he would provide his impression on the physicals. Director will meet with Dr. and inform him of the BDAP requirements.
When Dr. completes the exam the RN will check the physical paper work to make sure clinical impressions are documented.
Director will meet with Division Director to gain her assistance in making sure that the Dr. will add all of the information is required to be written on the physicals.
The RN and/or the CNA will make appointments for physicals soon as a client is admitted into the program so that the physical can be complete within the allotted time frame.
Dr.'s in the West Chester are being researched to aid in the process of the pregnant clients receiving physicals in the 7 day window.
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709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge.
Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form].
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
.Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility ' s policy and procedure manual contained a second written policy titled: " FOLLOW UP INFORMATION. " This second policy states: "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."
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Plan of Correction
The facility's policy and procedure manual was reviewed May 9 ? 12, 2011 at Gaudenzia's Corporate Office. According to corporate guidelines, no individual facility may change any policy or form to suit facility needs. This citation regarding conflicting policies was reported to the Central Region Director and the CQI Director by the facility Program Director. The CQI Director revised the follow up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia website forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director.
On July 5, 2011 a meeting was held with the Program Director, Program Supervisor and Administrative Coordinator to review the policy on follow up procedures that Gaudenzia developed. A memo was distributed to all staff on July 7, 2011 explaining the procedure to be used effective immediately.
The new policy states; the first follow up will be completed no later than 7 days of discharge on all referred clients who have given written consent. Follow ups will be completed on all other discharged clients within 30 days regardless of discharge status.
Both follow ups will be documented on the same form.
Forms will be forwarded monthly to the Administrative Coordinator to be filed in the proper follow up log/binder. All forms will be reviewed monthly during the administrative meeting with the Program Supervisor, Administrative Coordinator and the Program Director. Follow up will be discussed during both clinical meetings and supervisory sessions. Follow up will be completed by designated clinical staff.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On May 26, 2011 the facility was again found to be out of compliance with the following standards:
709.51 Intake and admissions, physical examinations. This area of noncompliance was also identified during the May 11, 2010 (plan of correction submitted on 6/21/2010 and approved on 6/21/2010) and May 20, 2009 (plan of correction submitted on 6/19/2009 and approved on 7/09/2009) licensing inspections
704.11 Staff development program, infectious disease training. This area of noncompliance was also identified during the June 19, 2008 (plan of correction submitted on 7/29/2008 and approved on 7/30/2008) licensing inspection.
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Plan of Correction
All plans of correction action steps have been implemented. To ensure compliancy, the Program Director will meet with the Program Supervisor and respectively to review the approved POC. Each supervisor will then meet with their staff to review the POC. The Program Director shall be present for this meeting.
The Program Director will meet with the Program Supervisors monthly to review progress in the cited deficiency areas. This will be documented in Administrative Meeting minutes and /or supervisory notes.
Should the Program Director observe deviation from an approved POC, the Director will develop and implement an action plan for the Program Supervisors. In the future, should the Program Director experience difficulty with the POC compliance, the Program Director will immediately submit to the Department a request for extension or modification to the approved POC.
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