INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 9, 2009 licensure renewal inspection. The follow-up inspection was conducted on November 3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 November 27, 2009 .
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Plan of Correction
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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 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.
This cannot be re-evaluated until the next licensing inspection. Please resubmit the original plan of correction.
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Plan of Correction
The Staff were given the Training Required Form to fill out on 12/4/2009. The Clinical Staff met with Acting/Program Director during the Week of 12/7/2009 to discuss and schedule Trainings to meet Staff Training Criteria of having a minimum of 25 Training Hours annually. All Clinical Staff have been scheduled to attend trainings this month to meet requirements. The Support and House Management Staff will be scheduled to meet with the Director on 12/14/2009 to schedule Trainings to meet their Staff Training Hours.
To ensure compliance with Staff Traning requirements, a Training Form will be instituted to list all required Trainings and will be reviewed Quarterly by Acting/Program Director to maintain compliance. |
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 review of the temperature logs the facility failed to document daily records of the freezer temperature and the facility failed to keep frozen food at or below 0
Findings:
A review of the freezer temperature logs was conducted on November 3, 2009. The facility failed to document freezer temperatures on the following dates:
August 17, 2009, the facility failed to document the temperature between the hours of 8 a.m. and 4 p.m.
September 4, 2009 the facility failed to document the temperature between the hours of 8 a.m. and 4 p.m.
September 6, 2009 the facility failed to document the temperature between the hours of 8 a.m. and 4 p.m. and 4 p.m. and 12:00 a.m.
September 10, 2009, the facility failed to document the temperature between the hours of 8 a.m. an 4:00 p.m. .
September 14, 2009, the facility failed to document the temperature between 8 a.m. and 4:00 p.m.
September 18, 2009, the facility failed to document the temperature between 8 a.m. and 4:00 p.m.
September 21, 2009, the facility failed to document the time that the temperature was taken at during the 8 a.m. to 4:00 p.m. shift.
On September 28, 2009 the facility failed to document the temperature between the 8 a.m. and 4:00 p.m. shift.
Additionally, the facility failed to keep frozen food at or below 0 on the following dates:
August 15, 2009 the facility documented the freezer temperature as being 8 at 8:25 a.m., 12 at 8:00 p.m. and 8 at 4:00 a.m.
August 18, 2009 the facility documented the freezer temperature as being 18 at 8:00 a.m., 8 at 2:20 p.m., and 2 at 12:40 a.m.
August 24, 2009 the facility documented the freezer temperature as being 10 at 1:00 p.m. and 4 at 12:15 a.m.
August 29, 2009 the facility documented the freezer temperature as being 18 at 3:00 p.m. and 2 at 2:20 a.m.
August 30, 2009 the facility documented the freezer temperature as being 34 at 8:30 a.m.
September 2, 2009 the facility documented the freezer temperature as being 4 at 8:00 a.m. and 19 at 4:01 p.m.
September 9, 2009 the facility documented the freezer temperature as being 8 at 8:15 a.m.
September 11, 2009, the facility documented the freezer temperature as being 11 at 11:07 a.m. and 9 at 12:30 a.m.
September 15, 2009 the facility documented the freezer temperature as being 14 at 8:00 a.m. and 6 at 4:35 p.m.
September 16, 2009 the facility documented the freezer temperature as being 8 at 11:05 a.m. and 30 at 4:00 p.m.
September 17, 2009 the facility documented the freezer temperature as being 8 at 11:25 a.m. and 6 at 2:02 a.m.
September 19, 2009 the facility documented the freezer temperature as being 6 at 8:00 p.m.
September 20, 2009 the facility documented the freezer temperature as being 8 at 12:30 a.m.
September 21, 2009 the facility documented the freezer temperature as being 8 at 4:30 a.m.
September 23, 2009 the facility documented the freezer temperature as being 10 at 8:24 a.m., 20 at 4:00 p.m. and 10 at 2:20 a.m.
September 24, 2009 the facility documented the freezer temperature as being 7 at 11:00 a.m.
September 27, 2009 the facility documented the freezer temperature as being 14 at 8:15 a.m.
September 29, 2009 the facility documented the freezer temperature as being 30 between the hours of 4:00 p.m. and 12:00 a.m. No specific time was written down.
October 1, 2009 the facility documented the freezer temperature as being 16 at 4:17 p.m.
October 3, 2009 the facility documented the freezer temperature as being 6 at 8 a.m.
October 4, 2009 the facility documented the freezer temperature as being 6 at 8:15 a.m.
October 6, 2009 the facility documented the freezer temperature as being 6 at 4:00 p.m.
October 7, 2009 the facility documented the freezer temperature as being 6 at 4:00 p.m.
October 13, 2009 the facility documented the freezer temperature being 6 at 8:00 a.m.
October 14, 2009 the facility documented the freezer temperature as being 10 at 8:30 a.m.
October 18, 2009 the facility documented the freezer temperature as being 9 at 4:15 a.m.
October 19, 2009 the facility documented the freezer temperature as being 9 at 2:30 a.m.
October 23, 2009 the facility documented the freezer temperature as being 6 at 8:25 a.m. and 8 at 4:00 p.m.
October 26, 2009 the facility documented the freezer temperature as being 10 at 4:10 a.m.
October 27, 2009 the facility documented the freezer temperature as being 6 at 7:00 p.m.
October 28, 2009 the facility documented the freezer temperature as being 6 at 7:00 p.m.
October 30, 2009 the facility documented the freezer temperature as being 8 at 1:00 a.m.
November 1, 2009 the facility documented the freezer temperature as being 6 at 8:15 a.m.
November 2, 2009 the facility documented the freezer temperature as being 6 at 10:43 a.m.
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Plan of Correction
A. Acting/Program Director facilitated an in-service training with the House Management Staff on 12/9/2009 to discuss freezer runs and the importance of ensuring that runs are done on time and are accurate. They will also be required to check the freezer to ensure that there are no leaks, freezer door not being properly closed, temperature reads at zero or below and they will communicate immediately if it goes above zero as well as other maintenance checks.
B. Service Port Refrigeration was contacted on 12/4/2009 to come out and check the freezer for any malfunctions. Service Port Refrigeration came out on the same day to repair the freezer. Freon was added and condensation was taken care of, he also stressed the point of ensuring that the freezer door was properly shut.
Acting/ Program Director will ensure that previous follow-up and QI System is adhered to which includes information documented in the log book of all freezer run findings, and communications with the Safety Committee monthly to ensure that freezer runs are conducted daily and proper procedures for maintaining a zero or below temperature reading is met. |
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 of treatment and rehabilitation services in three of three client records.
Findings:
Three open client records were reviewed on November 3, 2009. Treatment plans were reviewed in three client records. The facility did not document treatment plans to include type of treatment and rehabilitation services in client records # 9, 10 and 11.
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Plan of Correction
Treatment and Rehabilitation Services and Treatment Plans will be revised to reflect the correct Treatment milieu and Program Manual Requirements. This will be effective 2/1/2010. An In-Service Training will be facilitated on 1/5/2010 to discuss the importance of type and frequency on Treatment Plans.
Acting/Program Director will review monthly all Treatment Plans to ensure that criteria for Treatment Planning is met.
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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 five of eight client records.
Findings:
Eight closed client records were reviewed on November 3, 2009. Follow-up information was required in eight 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 # 1, 3, 5, 6, and 7.
Client # 1 was discharged on 9/2/2009. No follow-up information was documented for this client.
Client # 3 was discharge 9/2/2009. No follow-up information was documented for this client.
Client # 5 was discharged on 9/4/2009. No follow-up information was documented for this client.
Client # 6, was discharged on 9/28/2009. No follow-up was documented for this client.
Client # 7 was discharged on 9/14/2009. No follow-up was documented for this client.
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Plan of Correction
An in-service will be facilitated on 12/17/2009 to inform Staff that we are only required to perform one follow-up within seven days after Discharge. Acting/ Program Director will designate a Clinical and House Management Staff Member to facilitate follow-ups. This will ensure that all individuals leaving the Program will have a follow up contact within seven days.
Acting/ Program Director will follow up monthly with designated Staff Members and review follow-up book to ensure that policy is followed. |