INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11-12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. People With Hope/Short-Term Program 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 onJuly 15, 2009.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of five personnel records, the facility failed to document close supervision in one of one counselor assistant's personnel records.
Findings:
Five personnel records were reviewed on June 11-12, 2009. One of the personnel records reviewed was a counselor assistant, requiring weekly documentation of close supervision for nine months. The facility did not document weekly close supervision notes for personnel #5.
Personnel #5 hire date was 8/25/08. Supervision notes in 2009 were documented on 1/6/09, 2/6/09, 3/6/09, 3/29/09 and 4/30/09.
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Plan of Correction
Clinical Supervisor or lead counselor that has at least a bachelor's degree in the related behavioral health studies/psychology studies will be responsible to monitor all groups/ individual sessions/seminars facilated by the counselor assistant requiring weekly supervision on a daily basis and sign off on all documentation on a weekly basis.Program Director will be responsible for supervisory follow ups. Division Director will be responsible for monitoring oversight. Corrective actions will be implemented to establish compliance by 8/30/09. |
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 at least 25 clock hours of training annually in one of one personnel records.
Findings:
Five personnel records were reviewed on June 11-12, 2009. One of the personnel records reviewed was a counselor, requiring documentation of 25 clock hours of training. The facility only had documentation for 18 hours of the required 25 hours for the 2008 training year in personnel record # 3.
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Plan of Correction
Program Supervisor will formulate individual training plans for counselor and enroll counselor in Motivational Interviewing,Cognitive Behavioral Counseling,Introduction to Gambling Addictions,Group Counseling, Suicide Prevention (totaling 30 hours)faciltated by Gaudenzia Training Institute. Program director will be responsible for Supervisory follow up on a monthly basis. Divisional Director will be responsible for monitoring oversight. Plan for correction will be implemented to establish compliance on 8/30/09. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of eight client records, five of which were reviewed for consent to release information forms, the facility failed to document the purpose for the disclosure of client information on a signed consent to release information form in two of five client records.
Findings:
Eight client records were reviewed on June 11-12, 2009. Consent to release information forms were reviewed in five client records. The facility did not document the purpose for disclosing client information in client records # 1 and 3.
Records # 1 and 3 documented the released client information to a government agency and to an insurance company, but the purpose for releasing the information was not documented.
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Plan of Correction
Porgram Director will be responsible to conduct a training for clinical & therapeutic support staff on the concise & comprehendable manner in which all consent forms releasing and obtaining information should be accurately completed on site and review completed forms during weekly chart audits to ensure all purpose information is documented on signed consents. Divisional Director will be responsible for monitoring oversight. Corrective actions will be implemented to establish compliance by 8/30/09. |
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 eight client records, five of which were reviewed for completion of physical examinations, the facility failed to document a physical examination within seven days from the date of admission as per facility policy and procedure in one of five client records.
Findings:
Facility policy titled "PHYSICAL EXAMINATION LABORATORY STUDIES", dated January, 2009, stated:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend."
Eight client records were reviewed on June 11-12, 2009. Physical examinations were reviewed in five client records. The facility did not document a physical examination within seven days of admission, as stated in the project ' s policy manual, in client record # 2.
Client record # 2 admission date 3/12/09, but physical exam not documented at time of inspection.
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Plan of Correction
Nursing Manager will be responsible to schedule all new admissions to have physical examinations completed by Medical Director within clients first week of admission. Nursing staff will schedule physical examinations with PCP(s)for special needs.Program Director will be responsible to follow up weekly with assigned nursing staff that physical was completed and filed in medical charts.Divisional Director will be responsible for monitoring oversight.Corrective actions will be implemented to establish compliance by 8/30/09. |
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 eight client records, five were reviewed for documentation of the type and frequency of treatment in the treatment plan. The facility failed to document treatment and rehabilitation plans to include type and frequency of treatment and rehabilitation services in five of five client records.
Findings:
Eight client records were reviewed on June 11-12, 2009. Treatment plans were reviewed in five client records. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1, 2, 3, 6 and 7.
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Plan of Correction
Program Supervisor will do an on site training for clinical staff on the treatment plan inclusive of noting(types)specific groups 1-7 x a week and individual sessions noted 1 x a week in frequency section of treatment plans. Porgram Director will be responsible for supervisory follow ups inclusive of feedback from weekly chart audits. Division Director will be responsible for monitoring oversight.Corrective actions will be implemented to establish compliance by 8/30/09. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of eight client records, four of which were reviewed for treatment plan updates, the facility failed to document a treatment plan update in four of four client records.
Findings:
Eight client records were reviewed on June 11-12, 2009. Treatment plan updates were reviewed in four client records. The facility did not document a treatment plan update to include an assessment of the client progress in relationship to the stated goals of the comprehensive treatment plan in client records # 1, 2, 3 and 6.
Client record #1 treatment plan update documented on 6/7/09 did not include an assessment of progress.
Client record #2 treatment plan updates documented on 4/13/09 and 5/6/09 did not include an assessment of progress.
Client record #3 treatment plan updates documented on 3/24/09, 4/24/09 and 5/24/09 did not include an assessment of progress.
Client record #6 treatment plan update documented on 6/11/09 did not include an assessment of progress.
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Plan of Correction
Program Supervisor will be responsible to document treatment plan update dates on review board posted in counselors' offices with verbal reminders communicated in weekly clinical team meetings to ensure prompt completion. Program Director will be responsible for supervisory follow ups. Division Director will be responsible for monitoring oversight. Corrective actions will be implemented to establish compliance by 8/30/09. |