D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.

GAUDENZIA, INC.
361 WEST FIFTH STREET
ERIE, PA 16507

Inspection Results Overview Definitions Surveys Additional Services Search

Survey conducted on 11/20/2009

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on November 20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. - Daniel Snow 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 December 18, 2009.	Plan of Correction
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.
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 two personnel records reviewed. The findings include: Four personnel records were reviewed on November 17, 2009. Two of the personnel records were counselors. Two personnel records were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4. Employee # 4 was hired on May 3, 2004. He was promoted to the counselor position on September 26, 2005. The facility training year is from January through December. The training year for January 2008 to December 2008 was reviewed. Employee # 4 only completed twelve clock hours of annual training in 2008. The director confirmed on that the counselor did not have the 25 clock hours of training for the 2008 training year.	Plan of Correction All staff will obtain required amount of training hours each year. This is effective immediately and will be monitored by the Program Supervisor, Division Director and the Director of Finance and Operations.
709.53(a)(3) LICENSURE Records of Service 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: (3) Record of services provided.
Observations Based on the review of client records, the facility failed to document individual counseling sessions on the record of services in four of four client records. The findings include: Four client records were reviewed on November 20, 2009. The record of services was required in four client records. The facility did not document the individual counseling sessions on the record of services in client records #1, 2, 3 and 4. Record #1 was admitted on 9-30-09. The record of service did not document the individual counseling sessions provided to the client. Progress notes documented that individual counseling sessions occurred on 10-2-09, 10-15-09, 10-29-09, and 11-13-09, but there are no entries on the record of service. Record #2 was admitted on 9-16-09. The record of service did not document the individual counseling sessions provided to the client. Progress notes documented individual counseling sessions occurred on 9-16-09, 9-21-09, 9-25-09, 10-8-09, 10-22-09, 11-5-09 and 11-19-09, but there are no entries on the record of service. Record #3 was admitted on 7-1-09 and was discharged on 9-29-09. The record of service did not document the individual counseling sessions provided to the client. Progress notes documented individual counseling sessions occurred on 7-2-09, 7-16-09, 7-29-09, 8-12-09 and 8-26-09, but there are no entries on the record of service. Record #4 was admitted on 5-22-09 and was discharged on 9-30-09. The record of service did not document the individual counseling sessions provided to the client. Progress notes documented individual counseling sessions occurred on 6-4-09, 6-18-09, 7-2-09, 7-16-09, 7-30-09, 8-13-09 and 9-21-09, but there are no entries on the record of service.	Plan of Correction All client records will contain a record of service that includes all applicable program activities. The Program Supervisor will re-train the clinical staff on 12/2/09. This will be monitored by the Program Supervisor, Division Director and in the monthly UR/QI meetings.
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.
Observations Based on a review of the client records, the facility failed to document progress notes which contained the data and the assessment in four of the four required records. The data should include information presented by the client during the counseling session, counselor observations and information about the client from other sources. The assessment should include the counselor's analysis of and conclusions regarding the client's current situation or status. In addition, two of the four client records did not document group progress notes. The findings include: Four client records were reviewed on November 20, 2009. Four of the four records were required to document progress notes that include the data and the assessment. Four of the four records, records #1, 2, 3 and 4, did not include this documentation. In addition, client records # 3 and 4 did not document group progress notes for several dates. Record #1 was admitted 9-30-09. The Relapse Prevention group progress notes that do not include data or assessment are dated October 14, 2009, October 21, 2009, October 28, 2009, November 4, 2009 and November 11, 2009. The Encounter group progress notes that do not include data or assessment are dated October 14, 2009, October 21, 2009, October 28, 2009, November 4, 2009 and November 11, 2009. Record #2 was admitted 9-16-09. The Relapse Prevention group progress notes that do not include data or assessment are dated September 23, 2009, October 14, 2009, October 21, 2009, October 28, 2009, and November 11, 2009. The Encounter group notes that do not include data or assessment are dated September 30, 2009, October 7, 2009, October 14, 2009, October 21, 2009, October 28, 2009, and November 4, 2009. Record #3 was admitted 7-1-09 and discharged 9-29-09. The Relapse Prevention group progress note that does not include data or assessment is dated September 23, 2009. The Encounter group progress notes that do not include data or assessment are dated August 19, 2009, and September 23, 2009. In addition, group sessions were documented on the record of service, but group progress notes were not documented. Encounter group notes are not documented for July 1, 2009, July 29,2009, and August 5, 2009. Relapse Prevention group notes are not documented for July 22,2009, July 29,2009, August 12, 2009, and August 26, 2009. There is one Encounter group progress note dated September 16, 2009 which was not signed by the counselor. Record #4 was admitted 5-22-09 and discharged 9-30-09. The Encounter group progress notes that do not include data or assessment are dated June 3, 2009, July 15, 2009, August 19, 2009. The Relapse Prevention group progress notes that do not include data or assessment are dated July 8, 2009 and September 23, 2009. Relapse Prevention group sessions were documented on the record of service, but Relapse Prevention group progress notes were not documented for the following dates; May 27, 2009, June 10, 2009, July 1, 2009, July 22, 2009, July 29,2009, August 12, 2009, and August 26, 2009. Encounter group sessions were documented on the record of service, but Encounter group progress notes were not documented for June 17, 2009, July 29, 2009, and August 5, 2009.	Plan of Correction A new clinical group feedback sheet was developed on 11/19/09. The Program Supervisor will train all clinical staff on the proper documentation of clinical groups on December 2, 2009. At that same training the Program Supervisor will train all clinical staff on writing individual session notes that contain effective "assessments". This will be monitored by the Program Supervisor, Division Director and reviewed in the monthly UR/QI meetings.