INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. West Chester 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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704.7(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 eight personnel records, it was determined that one employee hired as a counselor did not meet the qualification requirements for the position.
Employee #8 was hired as a counselor on May 15, 2023 and was current in that position at the time of the inspection. At the time of hire, the employee did not have a qualifying degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/3/2023, Employee #8's position was changed to Counselor Assistant in accordance with 704.7 (b). Program is in the process of completing an exception request for this employee due to the length of time as a Counselor and prior agency/employer being granted this request.
To prevent reoccurrence, Program Director and Clinical Supervisor will review resume to ensure experience and credentials are in alignment with 704.7 (b). Furthermore, in the event that an exception is requested, program will submit at the time of hire.
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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 eight personnel records, the facility failed to ensure that one applicable employee received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee #3 was hired as a counselor on April 11, 2022 and was due to have the communicable disease trainings no later than April 11, 2023. However, the HIV/AIDS training was not documented as complete until May 31, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As noted in the citation/finding, Employee #3 completed the training on May 31, 2023, which was past the required one-year timeframe for Counselors to have completed this training.
As a means of ensuring that Counselors and all other Program Support Staff complete this training within the required/outlined timeframe, Program Director will work with Administrative Coordinator (monthly) and staff (quarterly) to ensure that all staff complete the required trainings within the established timeframes.
During monthly supervision with Administrative Coordinator, Program Director and Administrative Coordinator will review the training records of all employees. Program Director and Administrative Coordinator will review each employee's training record using our web-based Relias training system, on a quarterly basis, as a standing agenda item in the Staff Meeting, which will be notated in the Staff Meeting minutes, along with expectations of training completion to ensure compliance with this standard. The first review of training records will take place on 7/13/2023 (with Administrative Coordinator) and 7/26/2023 (with all Staff).
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on June 1, 2023, the facility failed to keep the grounds of the facility clean safe and in good repair at all times for the safety and well-being of residents, employees and visitors. There were layers of warped plywood at the bottom of the emergency exit stairs that posed a potential tripping hazard for those using the exit or walking around the perimeter of the building.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 1, 2023, Program Director had the pieces of plywood removed and placed in the Dumpster that was on property.
As a means of ensuring compliance with the abovementioned licensing standards, Program Director will review this licensing standard and expectations with all staff during next General Staff Meeting (July 26, 2023) to ensure awareness of expected practice and compliance.
Program Director and/or designee will monitor the grounds monthly during completion of monthly safety report/inspection to ensure building exterior is free and clear of any hazards. Program Director and/or designee will inform necessary party/ies to ensure that any identified issues are rectified within forty-eight (48) hours.
On a quarterly basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their physical plant tours and completion of the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
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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 on June 1, 2023, the facility failed to keep frozen food at or below 0 degrees Fahrenheit, as the exterior freezer was 32 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On June 1, 2023, when Program staff realized that the outside freezer continued to read in excess zero degrees, Food Service Manager contacted contracted repair to have the freezer checked to determine the cause of elevated temperature. Technicians arrived on-site on June 2, 2023, and they were able to ascertain and fix the cause of the elevated temperature.
As a means of ensuring compliance with the abovementioned licensing standards, Program Director will review this licensing standard and expectations with all staff during next General Staff Meeting (July 26, 2023) to ensure awareness of expected practice and compliance, which includes the continued monitoring and documentation of inside and outside refrigerator/freezer temperatures.
The Food Service Manager and/or designee will review the temperature logs and contact contracted technicians if the temperatures are outside of the established storage temperatures. Program Director will monitor the temperature logs during monthly supervisory sessions with Food Service Manager to add an additional layer of oversight to ensure compliance with established licensing standards.
On a quarterly basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their physical plant tours and completion of the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on June 1, 2023, the facility failed to ensure that the date of the fire extinguisher inspection was indicated on the extinguisher or tag, as the second floor hallway contained a fire extinguisher without a tag or other notation of annual inspection and approval.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 7, 2023, the tag on the Fire Extinguisher was replaced.
As a means of ensuring compliance with the abovementioned licensing standards, Program Director will review this licensing standard and expectations with all staff during next General Staff Meeting (July 26, 2023) to ensure awareness of expected practice and compliance.
Program Director and/or designee will continue to conduct monthly inspections of the fire extinguishers to ensure that each fire extinguisher is operable and contains an inspection tag. In the event that any fire extinguishers are missing tags, Program Director and/or designee will inform necessary party/ies to ensure that any identified issues are rectified within forty-eight (48) hours.
On a quarterly basis, the Quality Assurance Department will also monitor Program's compliance with the abovementioned standard, which will be completed during their physical plant tours and completion of the physical plant audit tool. Any issues identified will be brought to the immediate attention of the Program Director and rectified within forty-eight (48) hours.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of seven records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in one record reviewed.
Client # 4 was admitted on January 19, 2023 and discharged on March 8, 2023. The record contained a consent to release information form to the funding source signed by the client on January 19, 2023, that was missing the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will implement a biweekly review of all new admissions to ensure that all necessary consent forms include the specific information to be disclosed. This review will be to be completed by the Program Director and Intake Specialist during biweekly supervisory sessions. Any identified deficiencies will be rectified within 48 hours.
In addition to this, Program Director will be responsible for ensuring that this workflow expectation/addition is followed during monthly audits of all individuals admitted to the program.
This compliance with licensing standard will also be monitored on a quarterly basis by Division Director (or designee). In addition to this, compliance with this plan of correction and licensing standards will also be monitored by the Regional Quality Assurance Manager during quarterly audits of program charts.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of seven client records, the facility failed to follow their policy and procedures related to medication administration and recordkeeping in four of seven applicable records reviewed. The facility ' s policy manual provided two ways that medication administration records were to be kept, one electronically and one on paper records. While reviewing the medication administration records neither policy was being consistently followed for each client. Clients reviewed had both paper and electronic records, however the medication was not documented on each method. The date and time of administration of medication could not be tracked utilizing one method due to different individuals at different times were documenting in various methods rather than on both to ensure accuracy.
Client # 4 was admitted on January 19, 2023 and discharged on March 8, 2023. Neither the paper nor electronic MAR records were complete.
Client # 5 was admitted on March 10, 2023 and was active at the time of the inspection. Neither the paper nor electronic MAR records were complete.
Client # 6 was admitted on April 4, 2023 and was active at the time of the inspection. Neither the paper nor electronic MAR records were complete.
Client # 7 was admitted on May 9, 2023 and was active at the time of the inspection. Neither the paper nor electronic MAR records were complete.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Medical Staff of West Chester House on July 18, 2022, to review the agency's policy regarding documentation expectations of medication monitoring and recording.
Program Director will be responsible for ensuring that this workflow expectation/addition is followed during monthly audits of charts, to include the MAR. Program Director will review the MAR's on a monthly basis to ensure that the records are complete. Any incomplete MAR's will be brought to the attention of the appropriate party and immediately rectified.
This compliance with licensing standard and plan of correction will also be monitored on a quarterly basis by Division Director (or designee). In addition to this, compliance with this plan of correction and licensing standards will also be monitored by the Regional Quality Assurance Manager during quarterly physical plant tours.
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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 and the facility's policies and procedures, the facility failed to document a psychosocial evaluation, within 72 hours of admission, in three of seven applicable records reviewed.
Client # 3 was admitted on November 30, 2022 and was discharged on January 2, 2023. The record did not contain a psychosocial evaluation.
Client # 4 was admitted on January 19, 2023 and discharged on March 8, 2023. The psychosocial evaluation was not completed until February 13, 2023.
Client # 5 was admitted on March 10, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on July 18, 2022, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completion of psychosocial evaluations.
Clinical Supervisor will perform biweekly audits of program admissions to ensure completion of psychosocial evaluations within established timeframes. Any identified deficiencies will be noted and addressed within 48 hours. Clinical Supervisor and Program Director will review audits for completeness during biweekly supervision. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies have been completed.
This compliance with licensing standard and plan of correction will also be monitored on a quarterly basis by Division Director (or designee). In addition to this, compliance with this plan of correction and licensing standards will also be monitored by the Regional Quality Assurance Manager during quarterly chart audits. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a preliminary treatment plan within five days of admission, in three of seven applicable records reviewed.
Client # 3 was admitted on November 30, 2022 and was discharged on January 2, 2023. The record did not contain a preliminary treatment plan.
Client # 4 was admitted on January 19, 2023 and discharged on March 8, 2023. The preliminary treatment plan was not completed until February 13, 2023.
Client # 5 was admitted on March 10, 2023 and was active at the time of the inspection. The preliminary treatment plan was not completed until May 3, 2023.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on July 18, 2022, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completion of preliminary treatment plans.
Clinical Supervisor will perform biweekly audits of program admissions to ensure completion of preliminary treatment plans within established timeframes. Any identified deficiencies will be noted and addressed within 48 hours. Clinical Supervisor and Program Director will review audits for completeness during biweekly supervision. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies have been completed.
This compliance with licensing standard and plan of correction will also be monitored on a quarterly basis by Division Director (or designee). In addition to this, compliance with this plan of correction and licensing standards will also be monitored by the Regional Quality Assurance Manager during quarterly chart audits. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of six applicable records reviewed.
Client # 1 was admitted on July 14, 2022 and was discharged on August 29, 2022. The treatment plan completed on July 16, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the week of August 1, 2022.
Client # 4 was admitted on January 19, 2023 and discharged on March 8, 2023. The treatment plan completed on February 13, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between February 16, 2023 and the date of discharge.
Client # 5 was admitted on March 10, 2023 and was active at the time of the inspection. The treatment plans completed on May 3, 2023, May 11, 2023, and May 15, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between April 26, 2023 and May 24, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on July 18, 2022, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completion of progress notes in accordance with treatment plans.
Clinical Supervisor will perform biweekly audits of clinical charts to ensure completion of progress notes in accordance with treatment plans. Any identified deficiencies will be noted and addressed within 48 hours. Clinical Supervisor and Program Director will review audits for completeness during biweekly supervision. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies have been completed.
This compliance with licensing standard and plan of correction will also be monitored on a quarterly basis by Division Director (or designee). In addition to this, compliance with this plan of correction and licensing standards will also be monitored by the Regional Quality Assurance Manager during quarterly chart audits. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include a discharge summary, in two of four applicable records reviewed.
Client # 3 was admitted on November 30, 2022 and was discharged on January 2, 2023. There was no documentation of a discharge summary in the record.
Client # 4 was admitted on January 19, 2023 and discharged on March 8, 2023. There was no documentation of a discharge summary in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on July 18, 2022, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completion of continuing care/discharge summaries.
Clinical Supervisor will perform biweekly audits of program discharges to ensure completion of continuing care/discharge summaries. Any identified deficiencies will be noted and addressed within 48 hours. Clinical Supervisor and Program Director will review audits for completeness during biweekly supervision. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies have been completed.
This compliance with licensing standard and plan of correction will also be monitored on a quarterly basis by Division Director (or designee). In addition to this, compliance with this plan of correction and licensing standards will also be monitored by the Regional Quality Assurance Manager during quarterly chart audits. |
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 client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in two of four applicable records reviewed.
Client # 1 was admitted on July 14, 2022 and was discharged on August 29, 2022. There was no documentation of follow-up information in the record.
Client # 4 was admitted on January 19, 2023 and discharged on March 8, 2023. There was no documentation of follow-up information in the record.
This is a repeat citation from the June 29, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An In-Service Training will be conducted with the Clinical Staff of West Chester House on July 18, 2022, to review the agency's policy regarding Clinical Documentation timeframes and expectations. This in-service training will include, but will not be limited to, completion of client follow-up post discharge.
Clinical Supervisor will perform biweekly audits of program discharges to ensure completion of follow-up notes on all individuals that have been discharged from the program. Any identified deficiencies will be noted and addressed within 48 hours. Clinical Supervisor and Program Director will review audits for completeness during biweekly supervision. Program Director will be responsible for ensuring that this workflow expectation/addition is followed, and any identified deficiencies have been completed.
This compliance with licensing standard and plan of correction will also be monitored on a quarterly basis by Division Director (or designee). In addition to this, compliance with this plan of correction and licensing standards will also be monitored by the Regional Quality Assurance Manager during quarterly chart audits. |