INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 5, 2019 of Gaudenzia Re-Entry House by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia 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:
|
Plan of Correction
|
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to follow their policy in regards to completion of the assessment of staff training needs. The Plan for Assessing Staff Training Needs policy stated "The training plan shall be ready for implementation effective Jan. 31st of each year." The overall training plan for the project was not completed until May 16, 2019.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The relevant Gaudenzia Policy has been revised to state that, "Program-level training needs assessments are due to the Training department by the end of January of each year. Upon receipt of the program-level annual assessments of staff training needs, the Director of Training and Education, in collaboration with the Project Director, will review the assessments in detail and develop a plan to address the training needs of the agency. The annual agency-wide training plan shall be ready for implementation no later than April 30th of each year." The Gaudenzia Director of Training and Education will ensure that this is completed within the designated timeframe each year. |
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.
|
Observations
Based on a review of personnel records, employee #1 was not trained in fire extinguisher use upon hire. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation that the employee received the training as of the date of this inspection June 5, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (c) (4) - 705.28 (c) (4) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required fire extinguisher training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
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.
|
Observations
Based upon a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on March 4, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1 ' s personnel record indicating the employee had been trained on what to do during emergencies as of the date of this inspection on June 5, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director completed this training on 6/7/19 and documentation of this has been placed in his file. All relevant staff within the HR and Training departments will review the DDAP 705.10 (d) (3) regulations by 7/31/19, and as the head of the Training department, the Director of Training and Education will be ultimately responsible for ensuring that all staff (to include administrative staff) receive required emergency procedure training upon hire. Training department staff will review all staff files during the orientation process to ensure that this training is completed. |
709.28 (c) 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.
|
Observations
Based on the review of seven client records on June 5, 2019, the facility failed to document an informed and voluntary consent to release information prior to disclosure of information in client records #5 and #6.
Client #5 was admitted on January 28, 2019 and discharged on March 1, 2019. There were no consent to release information forms in the client's record. The client's record showed a funding source, but no consent was in the file for the funding source. In an interview with the facility director, acknowledgement was made that a consent to the funding source should have been in the file as billing would have begun on the day of admission.
Client #6 was admitted on January 30, 2019 and discharged on March 24, 2019. There was no consent to release information form for the funding source. In an interview with the facility director, acknowledgement was made that a consent to the funding source should have been in the file as billing would have begun on the day of admission.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
An In-Service Training will be conducted with all Clinical/Administrative Staff on July 11, 2019 geared around Informed and Voluntary Consents to Release Information. Emphasis will be placed on educating and/or re-educating staff about ensuring that these consents are completed and filed in the electronic health record system.
Furthermore, during routine audits/review of electronic health records, Program Director will ensure that all records contain the consents to release information to all entities involved in client's treatment.
|
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.
|
Observations
Based on the review of seven client records on June 5, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. code 255.5(b) for releases of information in client record #1.
Client #1 was admitted on February 11, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on February 11, 2019 to probation that allowed for the release of urine screens.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
An In-Service Training will be conducted with all Clinical/Administrative Staff on July 11, 2019 geared around Informed and Voluntary Consents to Release Information. Emphasis will be placed on educating and/or re-educating staff about ensuring that these consents are completed and filed in the electronic health record system.
Furthermore, during routine audits/review of electronic health records, Program Director will ensure that all consents to release information are completed in accordance with the limits established by 4 Pa. code 255.5(b).
|
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.
|
Observations
Based on a review of seven client records on June 5, 2019, there was no documentation the clients received counseling services according to their individual comprehensive treatment plan in five records reviewed.
Client #1 was admitted on February 11, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated February 12, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client had received no individual sessions between April 30 - May 12, 2019.
Client #3 was admitted on September 24, 2018 and discharged on December 10, 2018. The comprehensive treatment plan, dated September 27, 2018, indicated weekly individual and group sessions. The record of service and progress notes indicated the client had received no individual sessions after November 2, 2018 and no group sessions after November 21, 2018.
Client #4 was admitted on September 17, 2018 and discharged on January 18, 2019. The comprehensive treatment plan, dated September 20, 2018, indicated weekly individual and group sessions. The record of service and progress notes indicated the client had received one individual session on December 3, 2018. The client's first group session was on October 24, 2018. The client did not receive any group sessions between November 8 - 25, 2018.
Client #5 was admitted on January 28, 2019 and discharged on March 1, 2019. The comprehensive treatment plan, dated February 4, 2019, indicated weekly individual sessions. The record of service and progress notes indicated the client had received no individual sessions during his duration at the facility.
Client #7 was admitted on March 11, 2019 and was still active at the time of the inspection. The comprehensive treatment plan, dated March 14, 2019, indicated weekly individual and group sessions. The record of service and progress notes indicated the client's first group session was on March 26, 2019.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
An In-Service Training will be conducted with all Clinical Staff on July 18, 2019 geared around Clinical Recordkeeping Guidelines/Expectations. Emphasis will be placed on reviewing Clinical Recordkeeping Guidelines, Timeframes, and Expectations. Program Director will review the importance of ensuring that the services provided/documented, meet and/or exceed, the services prescribed on an individual's treatment plan (s).
Furthermore, during routine audits/review of electronic health records, Program Director will ensure that all records contain documentation that meets, and/or exceeds, the services prescribed on an individual's treatment plan (s).
|