INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 8 and 9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Washington 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 July 3, 2009.
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Plan of Correction
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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 the review of personnel records on May 5, 2009, the facility failed to document that each counselor completed at least 25 clock hours of training annually for the 2008 training year.
Findings:
Seven personnel records were reviewed on May 5, 2009. Two counselors required at least 25 clock hours of training for the 2008 training year. The facility failed to document at least 25 clock hours of training for the 2008 training year for employee #5.
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Plan of Correction
Clinical Supervisor will review counselor training hours quarterly for compliance. Program Director will review with Supervisor semi-annually.
This will begin by 7/30/09. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan developed with the client in five of seven client records.
Findings:
Seven client records were reviewed on June 8 and 9, 2009. An individual treatment and rehabilitation plan developed with the client was required in seven client records.
The facility did not document individualized treatment plans developed with the client in five of seven records reviewed, records # 1, 2, 3, 5 and 7.
The treatment plans were identical in the statement of goals and action steps.
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Plan of Correction
Clinical Supervisor will review individualized treatment plans monthly with the primary counselors during supervision. Program Director and Clinical Supervisor will hold in-service training by 7/30/09. Program Director will review tx plans for the next three months for compliance. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in five of seven client records.
Findings:
Seven client records were reviewed on June 8 and 9, 2009. Treatment plans with proposed types of supportive services were required in seven client records. The facility did not document treatment plans with proposed types of supportive services in five of seven client records reviewed, #1, 2, 3, 5 and 7.
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Plan of Correction
Supportive services will be placed into the master comprehensive treatment plan and followed throughout the course of treatment. Clinical Supervisor will review monthly for compliance and will do in-service with primary counselors by 7/15/09. Director will review quarterly for compliance. |
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.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in five of five client records.
Findings:
Seven client records were reviewed on June 8 and 9, 2009. Counseling services provided according to the individual treatment and rehabilitation plan were required in five client records. The facility failed to document, either in the record of services or progress notes, that counseling services were provided according to the individual treatment and rehabilitation plan in five of seven client records reviewed, #1, 2, 3, 4 and 5.
Individual sessions were prescribed one time per week in client record #1. The facility documented individual sessions on 3/17, 3/19, 3/26, 4/2, 4/17, 5/1, 5/15 and 6/1/009.
Individual sessions were prescribed for one time per week in client record #2. The facility documented individual sessions on 3/31, 4/8, 4/15, 4/23, 4/28, 5/15 and 5/28/09.
Individual sessions were prescribed one time per week in client record #3. The facility documented individual sessions on 1/16, 1/22, 1/29, 2/4, 2/19, 3/9, 3/24, 4/9, 4/24, 5/8 and 5/21/09.
Individual sessions were prescribed for one time per week in client record #4. The facility documented individual sessions on 1/27, 1/30, 2/12, 2/27, 3/12, 3/26, 4/7, 4/24 and 5/1/09.
Individual sessions were prescribed for one time per week in client record #5. The facility documented individual sessions on 12/16, 12/23, 1/9, 1/23, 2/9, 2/23, 3/5, 3/16, 4/9 and 4/27/09.
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Plan of Correction
Tx Plans will reflect 1 hour per week for the first thirty (30) days and 2x per month thereafter. Clinical Supervisor will insure compliance when signing off on treatment plans. THis began as of 6/15/09. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document a complete client record to include medication records in three of seven client records reviewed.
Findings:
Seven client records were reviewed on June 8 and 9, 2009. A complete client record to include medication records was reviewed for three client records.
The facility failed to document a complete client record to include medication records in client records #1, 2 and 3. The facility failed to document the administration of medication to client #1 on 6/1 and 6/7/09.
The facility failed to document the administration of medication to client #2 on 6/1 and 6/4/09. The facility failed to document the administration of medication to client #3 on 6/1 through 6/7/09.
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Plan of Correction
House managers will be given in-service on completing MARS documentation by agency nurse by 7/30/09. Director will review MARS monthly for compliance with agency nurse. |