INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 25 - 26, 2011 licensure renewal inspection. The follow-up inspection was conducted on October 26, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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
At the time of follow-up review, on October 26, 2011, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the Staffing Requirements Facility Summary Report was not yet due to be completed. Facility must resubmit original plan of correction.
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 employees # 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.
This was still out of compliance at the time of the follow-up conducted on October 26, 2011.
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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 coordinator 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
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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
At the time of follow-up review, on October 26, 2011, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the 25 clock hours of annual training for counselors were not yet due to be completed. Facility must resubmit original plan of correction.
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.
This was still out of compliance at the time of the follow-up conducted on October 26, 2011.
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Plan of Correction
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 coordinator will develope a grid with all staff trainings as reminder so that the employee will not miss a scheduled training, schedule trainings will pop up as reminder and administrative coordinator will assure training are attended.
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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, the facility failed to document that fire extinguisher training was provided upon employment in two of six personnel records reviewed.
The findings include:
Four personnel records were review on October 26, 2011 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 # 4 and 5
Employee # 4 was hired on September 5, 2011; the training certificate in employee # 4's personnel record indicated this training did not occur until October 1, 2011.
Employee # 5 was hired on October 11, 2011; there was no certificate of training documented in employee # 5's personnel record reviewed.
This is a repeat citation. The facility was previously cited for noncompliance of this standard during the May 25 - 26, 2011 licensing inspection.
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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 date indicated.
After training is completed each staff shall receive a certificate indicating that training was completed with date that training was completed,certificate will be placed in individuals personnel file on site and a copy will be sent to the corporate office.
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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, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in two of six personnel records reviewed.
The findings include:
Four personnel records were review one October 26, 2011 for documentation that all personnel on all shifts had been 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 two of four personnel records reviewed, specifically, records # 4 and 5.
Employee # 4 was hired on September 5, 2011, but the training certificate indicated employee # 4's training to address emergency situations did not occur until October 1, 2011.
Personnel # 5 was hired on October 11, 2011; there was no documentation that employee # 5 received this training.
This is a repeat citation. The facility was previously cited for noncompliance of this standard during the May 25 - 26, 2011 licensing inspection.
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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.
The Director will supervisor house manger supervisor to assure this is done in a timely fashion.
The 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 to assure that training is completed as scheduled within th seven day time frame.
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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 physical examinations in accordance with the project's policies and procedures in seven of eight client records.
The findings include:
Eight client records were reviewed on October 26, 2011 for physical examinations. The facility neglected to record the physician's impressions in the physical examination in five client records, # 1, 2, 5, 7 and 8. Additionally, the physical exam was documented late in client record # 6. One client record, #4 did not have documentation of a physical exam.
The facility policy titled; PHYSICAL EXAMINATION LABORATORY STUDIES stated:
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 # 1 was admitted on September 23, 2011. The physical examination was completed on September 30, 2011 and did not include documentation of the physician's overall impression of the client.
Client # 2 was admitted on July 18, 2011. The physical examination was completed on July 25, 2011 and did not include documentation of the physician's overall impression of the client.
Client # 4 was admitted on September 6, 2011 The physical examination was due to be completed by September 12, 2011 and had not been documented as of the date of inspection.
Client # 5 was admitted on September 23, 2011. The physical examination was completed on September 26, 2011 and did not include documentation of the physician's overall impression of the client.
Client # 6 was admitted on October 5, 2011. the physical examination was to be completed by October 11, 2011 but was completed on October 17, 2011.
Client # 7 was admitted on October 5, 2011, The physical examination was completed on October 12, 2011 and did not include documentation of the physician's overall impression of the client.
Client # 8 was admitted on September 21, 2011. The physical examination was completed on September 14, 2011 and did not include documentation of the physician's overall impression of the client.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the May 25 - 26, 2011 licensing inspection.
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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.
A new medical director has been appointed to Gaudenzia Eastern Region, she will perform physicals that are not able to be performed within the alloted time stated in policy and proceedure mannual.
Intake is working more aggressively to have physicals upon admission. This area will be overseen by medical director and program director. Nurse/CNA will report any problems to director.
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