INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29-30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Erie 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 February 29, 2008.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the facility summary report and the calculation of the client/counselor ratio on 1-30-08, the facility failed to provide a full time clinical supervisor for every eight full time equivalent counselors.
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Plan of Correction
The addition of a Full Time Clinical supervisor would present a hardship that the program could not indure.
A re analysis of the data presented to the department indicated 8.125 staff FTE's at the time of inspection.
By reducing the clinical hours of the staff at Gateway Erie we can achieve FTE's of six. Considering a previous waiver of a ratio of 10::1. the ratio of patients to staff for work release at the time of inspection would equate to four FTE's for a census of forty for work release.
The inpatient requirement of 8::1.would require 1.75 FTE'S. We are staffing with two FTE's. The total FTE's is six.
In addition the requirement for Out patient at the Erie County Prison is 35::1. We had reported 1.2 FTE's. Considering that half the therapists hours are devoted to an unlicensed program. we will reduce the ETE's to .75 FTE's. This will adequately cover a census of six patients at the time of inspection.
The total aggregate of staff FTE's would equal 6.75; well below the eight FTE's, and providing a caseload for couselors that is within the requirements of staffing requirements. |
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 the personnel records and a discussion with the facility director, the facility failed to provide documentation to verify qualifications for the counselor position. Refer to employee record #3.
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Plan of Correction
Verification of degree status has been completed on 2/14/08.
This particular individual was not included in the ratio of staff to residents at the time of inspection. |
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 a review of the training records, the facility failed to provide an individual training plan for employee #1.
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Plan of Correction
The listed deficiency was with the Program Director's Training Plan. That deficiency was corrected on February 4,2008. The Director signed his training Plan and it was approved by his supervisor and submitted to Human Resources. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of the personnel records and a discussion with the facility director, the facility failed to provide a current work performance evaluation for one of one applicable employees. Refer to employee record #2.
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Plan of Correction
The Program Director's annual evaluation due in September was completed in February 2008.The Division Director has met with the Program Director regularly to provide supervision and direction of an ongoing basis despite the lack of having formalized documentation. There were no surprizes in the documented report. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a client record review on 1-29-08 and 1-30-08, the facility failed to provide an informed consent to release information. Two of seven records did not have a consent to release information form signed by the client prior to the disclosure of information. Refer to client records # 1 & 7. Specific information is not indicated on a consent to release information form in client record #1. The area reserved for documentation of the clients' wish to accept or reject a copy of the form was blank on 10 of 12 forms in client record #1.
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Plan of Correction
Training was provided during a staff meeting on 2/7/2008. Supervisors also addressed the issues with staff on an individual basis during supervisory sessions. Supervisors will provide checks of ROI's. In addition, during monthly chart audits ROI's will be examined and any recognized deficiencies will be corrected.
Finally all recognized deficiencies in the records have been corrected. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the documentation of the inspection of medication storage areas on 1-29-08, the facility failed to provide a monthly inspection, as required by facility policy and procedure, for September 2007.
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Plan of Correction
A checklist of Custody and Control issues has been developed by the Assistant Director and will be reviewed with the Director when the monthly report is presented to the Department of Corrections. Included in this data is the Inspection of the medication area and the Count of medications. |
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 client record review on 1-29-08 and 1-30-08, the facility failed to provide treatment plan updates in four of five client records. In addition to missing documentation, two of five client records did not have dates on the treatment plan updates. Without dates, it is not possible to determine if the updates were completed in accordance with policy and procedure and regulation. Refer to client records #3, 4, 5, & 6.
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Plan of Correction
The degree of "scatter" associated with clinical record citatons points to the lack of oversight on the part of the Director/Therapy Manager.
Consequenty, a form has been developed to provide presence or absence of essential documentation.
This form will be utilized by the Director/ Therapy Manager during monthly chart audits. Noted deficiencies will be documented and presented to the respctive clinical staff for correction.
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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 client record review on 1-29-08 and 1-30-08, the facility failed to provide progress notes in four of six client records. Refer to client records #2, 4, 5, and 6.
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Plan of Correction
The degree of "scatter" associated with clinical record citatons points to the lack of oversight on the part of the Director/Therapy Manager.
Consequenty, a form has been developed to provide presence or absence of essential documentation.
This form will be utilized by the Director/ Therapy Manager during monthly chart audits. Noted deficiencies will be documented and presented to the respctive clinical staff for correction.
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709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a client record review on 1-30-08, the facility failed to provide aftercare plans in two of two client records where due. Refer to client records # 4 and 6.
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Plan of Correction
The degree of "scatter" associated with clinical record citatons points to the lack of oversight on the part of the Director/Therapy Manager.
Consequenty, a form has been developed to provide presence or absence of essential documentation.
This form will be utilized by the Director/ Therapy Manager during monthly chart audits. Noted deficiencies will be documented and presented to the respctive clinical staff for correction.
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a client record review on 1-30-08, the facility failed to document discharge summaries for two of three client records. Refer to client records # 4 and 5.
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Plan of Correction
The degree of "scatter" associated with clinical record citatons points to the lack of oversight on the part of the Director/Therapy Manager.
Consequenty, a form has been developed to provide presence or absence of essential documentation.
This form will be utilized by the Director/ Therapy Manager during monthly chart audits. Noted deficiencies will be documented and presented to the respctive clinical staff for correction.
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