INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Re-Entry 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 and a plan of correction is due on July 11, 2009.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records, the facility failed to document CPR and first aid training to a sufficient number of staff persons.
Findings:
Six personnel records were reviewed on June 9, 2009. The facility did not document CPR and first aid training to a sufficient number of staff persons.
The facility did not document CPR and first aid training for the Van Driver(s).
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Plan of Correction
Program Director will ensure that all Staff will have updated certification for CPR/First Aid Training on every shift as outlined in Program Policy. Program Director will also follow up every three months to ensure that each Staff are in compliance. |
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 six personnel records, two of which were for counselors, the facility failed to document at least 25 clock hours of training annually in one of two personnel records.
Findings:
Six personnel records were reviewed on June 9, 2009. Two of the personnel records reviewed were for counselors, each requiring documentation of 25 clock hours of training.
The facility only had documentation for 12 hours of the required 25 hours for the 2008 training year in personnel record # 3.
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Plan of Correction
Program Director will ensure that all Clinical Staff will have full Training Hours required by Program.
Counselor#3 will be registered for the following Trainings:
1. Clinical Recordkeeping
2. Suicide Prevention
3. Group Counseling
4. Cultural Sensitivity |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to provide slip resistant surfaces in all bathtubs and showers.
Findings:
A physical plant inspection was conducted on June 9, 2009 at approximately 14:00. The facility did not provide slip resistant surfaces in all bathtubs and showers.
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Plan of Correction
House Manager will provide hourly maintenance checks to ensure that all showers have appropriate slip resistant mats in all bathtubs and showers and will report all deficiencies immediately to Program Director so that that they can be immediately replaced.
An assigned Point Person will discuss all safety issues and concerns at next monthly Safety Committee Meeting.
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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, the facility failed to keep frozen food at or below 0
Findings:
A physical plant inspection was conducted on June 9, 2009 at approximately 14:00. The facility did not maintain the freezer temperature at or below 0
The freezer temperature was 10 at the time of inspection.
The freezer temperature log consistently recorded temperatures above 0 since 5/17/09.
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Plan of Correction
A House Manager has been assigned to monitor and maintain temperature to both the refrigerator and freezer at all times.
Information will be documented in a log book and all findings will be reported immediately to Program Director and followed up at monthly Safefty Committee Meeting. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
Findings:
A physical plant tour was conducted on June 9, 2009 at approximately 14:00. The facility did not prohibit the use of heaters that are not permanently mounted or installed.
A portable space heater was observed in an office.
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Plan of Correction
House Manager will conduct all preventative safety maintenance checks during hourly rounds to ensure that Facility is in full compliance as outlined in Program Policy and will report all deficiencies immediately to Program Director.
Program Director will then send out a Memo alerting all Staff that no portable heaters are allowed on the property which is in violation of Program Policy which prohibits the use of Heating and Cooling Systems that are not mounted or installed.
An assigned Point Person will discuss all safety issues and concerns at next monthly Safety Committee Meeting.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment and rehabilitation plans to include type and frequency of treatment and rehabilitation services in three of three client records.
Findings:
Four client records were reviewed on June 9, 2009. Treatment plans were reviewed in three client records. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1, 2 and 3.
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Plan of Correction
All Treatment Plans will be tracked every three months at monthly CQI Meetings in the areas of Timeliness, Completeness and Effectiveness.
All Clinical Staff will attend additional In-Service Trainings which will address the areas of Type and Frequency of Treatment and Rehabilitation Services.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of two client records.
Findings:
Four client records were reviewed on June 9, 2009. Follow-up information was required in two client records. The facility did not document follow-up information within seven days after discharge, as stated in the project's policy manual, in client records # 3 and 4.
Client records #3 and #4 discharge date was 4/7/09. Follow-up information was documented but not dated. It could not be determined if follow-up was completed within seven days after discharge.
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Plan of Correction
Assigned Point Person will follow up on all Discharged Clients within 7, 14 and 30 days of Discharge. Program Director will assure that follow up on all Discharged Clients is conducted and documented.
Follow up will be studied and discussed at monthly CQI Meeting for Effectiveness, Timeliness and Completeness. |