INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Montgomery County Outpatient 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(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based on a review of personnel records, it was determined that one employee hired as a clinical supervisor did not meet the qualification requirements for the position.
Employee # 2 was promoted to the position of clinical supervisor on September 3, 2024 and was current in that position at the time of the inspection. At the time of promotion, the employee had a qualifying Master ' s degree, but only one year of clinical experience, not the required minimum of two years.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All potential candidates for all positions will have their qualifications carefully reviewed by the Division Director against all relevant DDAP regulations, to include 704.6(b) Qualifications for the Position of Clinical Supervisor. During this review, if there is any question as to whether a candidate is qualified, the hiring manager will reach out to DDAP for guidance. If the individual does not meet all qualifications, they will not be placed in that position. If any individual is found to have been placed in a position for which they are not currently qualified, they will be placed in a position which meets their qualifications. |
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 personnel files, the facility failed to ensure that one applicable clinical supervisor had completed a core curriculum in clinical supervision which is a requirement for the position.
Employee # 2 was promoted to the position of clinical supervisor on September 3, 2024 and is current in that position. Employee # 2 did not function for 2 years as a supervisor and has not completed a core curriculum as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within required timeframes.
This outstanding training will be completed absolutely as soon as they can be scheduled. This is anticipated to be no later than 6/20/25.
All staff members have an Individual Training Plan generated on their start date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements.
The Division Director will work with the staff member to schedule the trainings prior to the due dates and will monitor to ensure full and timely completion.
Certificates of completion as well as Evaluations will be maintained in the staff file.
The Division Director will review the Individual Training Plans weekly for new hires, and at least quarterly for all staff. Staff who have upcoming training due dates within the next quarter will be reminded of this and the Division Director will work with them to schedule training sessions prior to the due dates and will monitor to ensure full and timely completion. |
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 personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level per the facility's policy and procedures manual in two out of five employee records reviewed. The facility's policy and procedures manual states that the annual individual training plan is due by the end of January and the initial training plan is due by the date of hire.
Employee #2 was hired on May 15, 2023 and has been in the position of Clinical Supervisor since September 3, 2024. The individual training plan was not completed until March 25, 2025.
Employee #3 was hired on February 3, 2025 as a counselor and was still in the position as of the date of the inspection. The individual training plan was not completed until March 26, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Individual Treatment Plan (ITP) will be developed annually with input from both the employee and the supervisor, as specified in Gaudenzia Policy.
When the supervisor completes each employee's performance evaluation during the month of January, they will begin the process of evaluating the employee's training needs for the coming year. This will be finalized and signed off on by both the supervisor and employee within 1 year of the signature of the previous plan.
A specific form has been made available to be utilized by the supervisor and employee to document this process.
The Supervisor will conduct at least quarterly reviews of all ITPs, and any issues noted in the plan will be discussed and corrected by the supervisor and employee within one week. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 4 was admitted on September 5, 2024 and was involuntarily discharged on February 14, 2025. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All documentation will be completed correctly and in a timely manner.
The Clinical Supervisor will conduct a training with the clinical team on administrative discharge processes, paperwork, and client notification, specifically mailing a notice of termination of treatment to the client prior to the expected date of discharge by June 20th. The clinical team will sign off on the training. This training will include a detailed review of the standard; all relevant Gaudenzia policies; the Gaudenzia workflow document which specifies the required timeframes; the specific areas of the clinical chart in which to document this information, and; how to request assistance when needed.
The Clinical Supervisor will complete at least weekly reviews, and the Quality Assurance Manager will complete at least quarterly reviews of a representative sample of clinical charts utilizing our standard review tools which assess for the presence, timeliness and quality of each chart document.
Any issues noted will be reviewed by the Clinical Supervisor with the clinician responsible in a documented supervision session and corrected within 48 hours.
Progress in this area will be monitored by the Division Director and Deputy Director in regular supervision sessions, and any barriers to implementation addressed at that time. |