INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 25, 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. 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:
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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 personnel records, it was determined that one employee hired as a counselor did not meet the clinical experience requirements for the position.
Employee #5 was promoted to the position of counselor on March 27, 2023 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying bachelor ' s degree but not the required one year of clinical experience.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will ensure in the future that qualifications will be checked in the future to ensure employees are not hire into positions that they are not qualified for.
Employee # 5 is now qualified for the Counselor position since obtaining a master's degree in accordance with Regulation 704.7 (b) Counselor Qualifications. |
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 records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one applicable record.
Employee # 3 was hired as a counselor on May 5, 2014 and has remained in that position. The facility's training year that was reviewed was from January 2022 through December 2022. Employee #3's personnel record only documented 15 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director has ensured that Employee #3 has enrolled and completed trainings that total 25 training hours as required by 714.11 (f) (2).
Effective immediately, the Program Director will ensure that each Counselor completes the required number of trainings hours per 714.11 (f) (2) Training Hours Requirements-Counselors.
Program Director has implemented a monthly training schedule which will be submitted by each Counselor in order to help monitor training completion, in addition to the web-based Relias system.
The Program Director will review each staff training schedule on a monthly basis to ensure that each has enrolled in the DDAP approved trainings prior to due dates. Counselors will provide Certificates to be uploaded to the web-based system.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on May 25, 2023, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as each of the three trash receptacles in the courtyard of the building were uncovered.
This is a repeat citation from the June 7, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director called the trash disposal contractor and requested new containers to ensure compliance with Regulation 705.2 (4) Building exterior and grounds. We requested delivery of new containers. The company will notify the Director estimated date of delivery.
The Program Director will ensure that disposal containers lids are closed daily and has added this task to the daily oversight of the Residential Support Professional round sheet.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director for immediate correction.
Estimated time for delivery of New Trash Receptacles (exterior) is July 11, 2023.
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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection on May 25, 2023, the facility failed to ensure that bunk beds were equipped with securely attached railings as bunk beds in Bedrooms #328, 207, and 228 did not have railings.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director located railings for bedrooms #328#207 and # 228 and had them attached to the beds immediately on 5/25/2023.
The Program Director met with the entire community on 5/26/2023 to communicate that the railings cannot be removed and informed them that it is a safety requirement that they remain on the beds.
The Program Director met with Recovery Support Professionals (RSP) and Recovery Support Professional Supervisor on 5/26/2023 and informed them that during their daily rounds they are to ensure that all top bunk beds have the safety railing in place in accordance with Regulation 705.5 (b) Sleeping Accommodations. The Program Director also informed all RSP staff that it is to be reported immediately when the safety railing has been removed.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director for immediate correction.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on May 25, 2023, the facility failed to provide an operable soap dispenser in the bathroom of Bedroom #325.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director purchased hand soap to place in bathroom of bedroom # 325 immediately.
The Program Director also submitted a purchase order and maintenance request to have soap dispenser attached to the wall over the sink in bedroom #325. This is anticipated to be installed by 6/1/2023. Dispensers have been installed in bedroom #325
RSP staff will ensure during the hourly house runs that each bathroom has a soap dispenser and that all soap dispensers' have soap in them.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director for immediate correction.
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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 May 25, 2023, the facility failed to keep cold food at or below 40 degrees Fahrenheit, as the refrigerator next to the stove was 48 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director had the refrigerator removed and placed in the basement to ensure it would not overheat by being located directly next to the stove to ensure temperature is maintained at (40F) or below in accordance with Regulation 705.7 (b) (5) Food service. The refrigerator now reads at normal temperatures.
Temperature logs are maintained on a daily basis by RSPs. These are also monitored by the Program Director on a weekly basis.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director for immediate correction.
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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 inspection on May 25, 2023, the facility failed to ensure that heaters were permanently mounted as a space heater was found in the facility director ' s office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This heater was immediately removed from the office. The Program Director communicated during the monthly staff meeting held on June 8, 2023, that no portable heaters were allowed on the property.
The Program Director will ensure that RSP's observe that there are no heaters on the property. If heater is observed, the RSP will remove and lock item up until discharge if it is a client. If it is a staff member the staff member will be asked to take the heater off the property. This will be documented in a supervision note.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director for immediate correction.
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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 logs from June 2022 through April 2023, the facility failed to conduct unannounced fire drills at least once a month, as no fire drills were conducted during the months of June, August, and October 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that an unannounced Fire Drill is completed every month in accordance with Regulation 705.10 (d) (1) Fire Safety.
The Program Director will monitor the facility and review Fire Drill documentation prior to end of each month to ensure at Least 1 fire drill has been conducted and documented.
The Program Director will assign the RSP Supervisor the specific task of announcing the Fire Drill and ensuring that it is documented as required and filed for review.
The Program Director met with RSP Supervisor on 5/26/2023 to discuss and implement the process by which all unannounced Fire Drills will be conducted moving forward.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director for immediate correction.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from June 2022 through April 2023, the facility failed to prepare alternate exit routes as the same exit route was documented in each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that alternate routes are utilized when conducting unannounced Fire Drills.
The Program Director met with RSP Supervisor on 5/26/2023 to ensure that the facility utilizes alternate routes when conducting unannounced Fire Drills as required by 705.10 (d) (6).
The Program Director will review Fire Drill logbook monthly to ensure that (1) Fire Drill is being conducted and (2) that alternate routes are being utilized.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director for immediate correction.
Fire Drills completed for June 2023 has utilized alternative routes.
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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 specific information to be disclosed in two records reviewed.
Client # 3 was admitted on December 12, 2022 and was discharged on February 2, 2023. The record contained a consent to release information form for a family member signed by the client on December 12, 2022, that did not indicate the specific information to be disclosed.
Client # 4 was admitted on December 20, 2022 and was discharged on March 29, 2023. The record contained a consent to release information form to the funding source signed by the client on December 20, 2022, that did not indicate the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director met with Counselors during the weekly Clinical Team meeting to discuss ensuring the voluntary consents are completed for every client prior to speaking or releasing any information to external entities or individuals.
Director discussed with the Clinical Team on June 1, 2023 the importance of including specific information to be released ad who the information is being released on the consent to ensure that clarity of allowed information is clear.
The Program Director followed up by reviewing the voluntary consent for active clients and will continue to do so weekly.,
The Program Director reviewed the process with the Clinical Team as an agenda item in the weekly Clinical Team meeting on which meets every Thursday to ensure that each Counselor is aware of the requirement of Regulation 709.28 c Confidentiality.
The Program Director will review the chart for each admission to ensure that Voluntary Consents are being obtained as required.
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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 seven client records, the facility failed to ensure that intake procedures included documentation of physical examinations within seven days of admission in six records reviewed.
Client # 2 was admitted on August 11, 2022 and was discharged on October 15, 2022.
Client # 3 was admitted on December 12, 2022 and was discharged on February 2, 2023.
Client # 4 was admitted on December 20, 2022 and was discharged on March 29, 2023.
Client # 5 was admitted on February 6, 2023 and was active at the time of the inspection.
Client # 6 was admitted on April 6, 2023 and was active at the time of the inspection.
Client # 7 was admitted on March 17, 2023 and was active at the time of the inspection.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director met with Clinical Team and the Administrator of Intake process on June 1, 2023 to discuss and implement process of ensuring each client has either (1) document physical included in admission paperwork documented at admission, or (2) Counselor obtains an appointment for client within 7 days of admission and documents that upcoming appointment in the client's record for review.
The Program Director will review all charts within 7 days of admission to ensure that a physical was documented or that a date to obtain a physical was documented.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director to coordinate correction with the counselor within 48 hours.
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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 per facility policy, in three of seven applicable records reviewed.
Client #1 was admitted on June 9, 2022 and was discharged on September 13, 2022. The record did not contain a psychosocial evaluation.
Client # 6 was admitted on April 6, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 7 was admitted on March 17, 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
The Program Director reviewed the requirements of Regulation 709.51 (b) (6) Psychosocial evaluation with the Clinical Team during weekly Clinical Team meeting on 6/1/2023.
The Program Director met with specific Counselor of Client #1, Client #6, and Client #7 on June 1, 2023, to discuss documentation requirements.
The Program Director will review all new admissions within 72 hours to ensure that all Psychosocial evaluations have been completed within 72 hours as required by Regulation 705.51 (b) (6).
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director to coordinate correction with the counselor within 48 hours.
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709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records and the facility policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include progress notes completed immediately after therapy sessions, in three of seven records reviewed.
Client # 1 was admitted on June 9, 2022 and was discharged on September 13, 2022. The record contained progress notes for individual sessions occurring on August 19, 2022, and September 5, 2022, that were completed on September 26, 2022.
Client # 4 was admitted on December 20, 2022 and was discharged on March 29, 2023. The record contained progress notes for individual sessions occurring on February 13, 2023, January 30, 2023, and January 16, 2023, that were completed on February 26, 2023.
Client # 7 was admitted on March 17, 2023 and was active at the time of the inspection. The record contained a progress note for an individual session occurring on April 21, 2023, that was completed on April 27, 2023. Additionally, the record contained a progress note for an individual session occurring on April 18, 2023, that was completed on May 22, 2023. The record contained a progress note for an individual session that occurred on April 6, 2023, that was completed on April 15, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed DDAP findings with Clinical Team in the weekly Clinical Team meeting on June 1, 2023.
Effective immediately, the Program Director has implemented weekly chart reviews which will provide an opportunity to identify issues quickly and resolved in a timely manner.
The Program Director will address documentation issues in documented individual supervision sessions and will ensure that all documentation issues are resolved immediately upon identifying them.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director to coordinate correction with the counselor within 48 hours.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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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 case consultation information quarterly, in three of four applicable records reviewed.
Client # 1 was admitted on June 9, 2022 and was discharged on September 13, 2022. There was no documentation of case consultation information in the record.
Client # 4 was admitted on December 20, 2022 and was discharged on March 29, 2023. There was no documentation of case consultation information in the record.
Client # 5 was admitted on February 6, 2023 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has implemented a process of case discussion during weekly Clinical Team Meetings, at which each case presented will be documented by the corresponding Counselor to on a Case Consultation note to be submitted within 24 hours of the meeting. This process was reviewed with clinical staff on 6/1/2023 and implemented immediately.
The Program Director reviews client records weekly to ensure that Case Consultation notes are being recorded.
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director to coordinate correction with the counselor within 48 hours.
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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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in three of four records reviewed.
Client # 1 was admitted on June 9, 2022 and was discharged on September 13, 2022. The client record did not contain documentation of follow-up information.
Client # 2 was admitted on August 11, 2022 and was discharged on October 15, 2022. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on December 12, 2022 and was discharged on February 2, 2023. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/1/2023 during weekly Clinical Team meeting, the Director discussed findings with clinicians related to lack of documented follow up in 3 client records and reminded staff of this requirement.
The Program Director has implemented a process for weekly chart reviews for all discharges as well as an email follow up reminder to ensure that follow up calls are being completed and recorded according to Regulation 709.53 (a) (11).
This is also monitored during quarterly QA Manager reviews. Any issues noted are brought to the attention of the Program Director to coordinate correction with the counselor within 48 hours.
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