INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12-13 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie 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:
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of staff records conducted during the administrative review from September 10-13, 2019, the facility failed to ensure that all its staff had the required training.
Staff Person #3 was promoted to clinical supervisor on October 15, 2018, and the staff person had not functioned for two years as supervisor in the provision of clinical services at the time the staff person was promoted. Staff Person #3 did not complete the mandatory Department approved core curriculum in clinical supervision until August 9, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Clinical Supervisor has attended and completed the DDAP clinical Supervisors training. Moving forward all supervisors will have the Clinical Supervisors training within the required time frames. This will be monitored by the Program Director. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the project ' s policy and procedure manual conducted during the administrative review from September 10-13, 2019, the facility failed to complete its admission and treatment documentation within the time frames adopted by its governing body.
The project ' s policy and procedure manual reads that comprehensive/individualized treatment plans are to be completed within 30 days from the preliminary treatment plans for all outpatient programs.
The project ' s policy and procedure manual reads that biopsychosocial history and assessment must be completed within 30 days at outpatient levels of care.
The facility is an outpatient program.
Client #4 was admitted for treatment on December 19, 2018, and discharged on April 1, 2019, but there was no psychosocial evaluation for the client.
Client #4 ' s preliminary treatment plan was completed on December 19, 2018, but the client ' s individualized treatment plan was not completed until February 4, 2019.
Client #5 ' s preliminary treatment plan was completed on April 17, 2019, but the client ' s individualized treatment plan was not completed until June 21, 2019.
Client #6 was admitted for treatment on June 19, 2019, and the client was in treatment at the time of the on-site inspection, but there was no psychosocial evaluation for the client.
Client #7 was admitted for treatment on January 25, 2019, and the client was in treatment at the time of the on-site inspection, but there was no psychosocial evaluation for the client.
Client #7 ' s preliminary treatment plan was completed on January 25, 2019, but the client ' s individualized treatment plan was not completed until March 12, 2019.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The Clinical Supervisor will review the timeframes for documentation of the Comprehensive treatment Plan and the biopsychosocial assessment.
The Clinical Supervisor will review charts monthly to ensure compliance.
Compliance will be monitored in monthly program improvement meetings. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to ensure that it included all the required information on its consent to release information forms.
Client #2 ' s signed consent to release information form for the client ' s funding source did not include the name of the insurance company.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Client #2 was discharged.
The Clinical Supervisor will review the elements of a valid release of information with all staff in clinical supervision.
Releases of information will be reviewed during monthly chart audits by the clinical supervisor.
Compliance will be monitored in monthly program improvement meetings. |