INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 29-30, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. 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 May 22, 2009.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on an interview with the facility director and the clinical supervisor on April 29, 2009 at 9:30 AM, the facility failed to document an individual training plan for the current - 2009 - training year which commenced on January 1, 2009 .
The findings include:
During the annual onsite licensing inspection of April 29-30, 2009 an interview was held with the facility director and the clinical supervisor. At that time staff were told that each employee's annual training plan would need to be reviewed. The facility director stated that a 2009 training plan was not documented for her.
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Plan of Correction
Facility Director's training plan for 2009 was completed on 5-6-09. Director's training plan will be completed annually and timely for 2010 year by Director's supervisor, Central Region Director. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on an interview with the facility director and the clinical supervisor on April 29, 2009 at 9:30 AM, the facility failed to document the required 12 hours of annual training for the facility director for the training year ended December 31, 2008.
The findings include:
During the annual onsite licensing inspection of April 29-30, 2009 an interview was held with the facility director and the clinical supervisor . At that time staff were told that each employee's annual training hours would need to be reviewed. The facility director stated that no training hours were documented for her in the 2008 training year.
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Plan of Correction
Program Director will receive 12 hours of training annually as per policy from this time forward and it will be monitored by the Regional Director. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records on April 29-30, 2009, the facility failed to document the specific information to be released on consent to release information forms in five of five client records.
The findings include:
Five client records were reviewed during the annual licensing inspection. Each of the five records ( # 1, 2, 3, 4, 5) had a consent to release information in the event of an emergency. .The specific information to be released documented on each consent to release simply stated "emergency" and did not document what specific pieces of information would be released in the event of an emergency.
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Plan of Correction
Counselor III assigned to Middleburg will be trained by the Program Supervisor in the next supervisory session as to the specific information to be checked on consents/releases of information. This training will be documented on the supervisory session form. In the files mentioned by the licensing specialist, clients will be approached to re-sign those consents with specific information as to what can be released to the emergency contact.
Program Supervisor will monitor monthly during QA process for compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records on April 29-30, 2009, the facility failed to document complete personal histories in five of five client records.
The findings include:
At the time of the annual inspection, five client records were reviewed. None of the five records ( # 1, 2, 3, 4, 5) documented family dynamics as required by agency policy and as a part of a complete personal history.
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Plan of Correction
Program Supervisor will review the requirements for completion of personal histories with Counselor III, while correcting those records that were cited. This will be documented on a supervisory session form.
Program Supervisor will monitor the personal histories quality during the monthly QA to ensure compliance with training. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, interviews with agency staff and a review of the agency policy manual on April 29-30, 2009, the facility failed to document preliminary treatment plans for each client.
The findings include:
On April 29 , 2009 at 9:30 AM an interview was conducted with the facility director and the clinical supervisor. At that time it was determined that the preliminary treatment plan is not completed on the basis of the initial interview. Agency policy for Treatment Management states"..The admission session is one hour in length...During this session you need to complete the following:.. treatment plan...". Each of the five client records reviewed was required to have a preliminary treatment plan. None of these client records documented a preliminary treatment plan, client records # 1, 2, 3, 4 and 5.
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Plan of Correction
Program Supervisor will review policy and procedures regarding treatment plan with Counselor III. Documentation will be made on supervisory form regarding this training.
Program Supervisor will montiro during monthly QA process for compliance. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records on April 29-30, 2009 and an interview with the counselor assigned to this facility on April 30, 2009 at 9:50 AM, the facility failed to document a complete client record on each client.
The findings include:
While reviewing client record # 3 discrepancies in dates in the record were noted. The history and evaluation were dated November 12, 2007. The earliest treatment plan documented in the record was dated January 6, 2009. Client # 3 was in treatment continuously from November, 2007 until discharged in April of 2009. Progress notes, treatment plans and updates only accounted for the period from January 1, 2009 to the discharge date on April 9, 2009. This discrepancy was discussed with the counselor in an interview and she indicated that this occurred because the facility had changed hands. Prior to January, 2009 this facility was owned and operated by another licensed D&A provider. When the facility was acquired by Gaudenzia, Inc., the original owner took all portions of client treatment records completed under their ownership with them. The documents missing from the records included progress notes and treatment plans and updates. On the basis of the interview with the counselor, additional incomplete records were identified. These records were : # 6, 7, 8, 9, 10 , 11, 12, 13 and 14.
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Plan of Correction
From this time forward when Gaudenzia assumes responsibility for another drug and alcohol providers' program clients, in addition to obtaining releases from clients for the client record, the Department of Health, Division of Licensing will be notified of any refusal by the licensed drug and alcohol provider by the Program Director, Division Director and/or Regional Director.
A letter was sent ot Cheryl Williams, Director, Department of Health, Division of Licensing informing her of this situation. |