INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 19, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia- New Destiny 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of six personnel records, the facility failed to document that one counselor met both the education and experiential qualifications for the position.
Employee #5, who was hired as a counselor on January 23, 2023 and was still in that position at the time of the inspection. Employee #5 had a qualifying bachelor ' s degree, however, did not have the documented one year of clinical experience to qualify for the position.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The acting Program Director will assure that all counselors meet the educational and experiential qualifications for the position.
Employee #5 has been reclassified as a counselor assistant and will remain so until she is able to demonstrate at least 1 year (1,820 hours) of clinical experience. Employee is currently in pursuit of an accepted Master's Degree.
The Clinical Supervisor will provide ongoing close supervision until required minimum experience is obtained (at least 6 months).
Monitoring for compliance will occur monthly by the Clinical Supervisor and Program Director.
Target Compliance Date: 5/15/23 |
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.
|
Observations
Based on a review of personnel records and discussion with facility staff, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level that documented it was developed annually with input from both the employee and the supervisor in five out of six personnel records reviewed.
The individual training plans had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee #2 was hired on Aril 20, 2020 as a facility director and was still in that position as of the date of the inspection.
Employee # 3 was hired on November 20, 2021 as a clinical supervisor and was still in that position as of the date of the inspection.
Employee # 4 was hired on May 16, 2022 as a counselor and was still in that position as of the date of the inspection.
Employee # 5 was hired on January 23, 2023 as a counselor and was still in that position as of the date of the inspection.
Employee #6 was hired on July 6, 2022 as a counselor and was still in that position as of the date of the inspection.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Program Director/Supervisor met with all staff to discuss individualized training plans and in collaboration with the staff a written individualized training plan was completed based on employee and supervisor input and signed by each employee and supervisor.
Same procedure meeting with employee and completing training plans will occur ongoing with all newly hired employees and at least annually thereafter with monitoring by the Prog Director to assure compliance.
As electronic training plans are developed, Program Director/Supervisor will assure documentation of employee input and dated signature.
The Program Director/Supervisor will assure that staff training is received as planned/needed.
A monthly staff training report will be completed by Administrative staff for Prog Director ongoing monitoring to assure compliance.
Target Date: 5/22/23 |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The community bathroom located on the third floor had flooring in front of the toilet that was torn causing a potential tripping hazard.
This is a repeat citation from the April 26, 2022 licensing inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director and designee will assure that all bathrooms are maintained in a functional, clean, safe, and sanitary manner at all times.
An additional work order has been submitted into the Gaudenzia Maintenance System, requesting prompt repair to the torn flooring located in the 3rd floor community bathroom.
The Prog Director has spoken with the Regional Physical Plant Manager to coordinate prompt repair.
Physical plant safety issues will be included on the monthly safety report, submitted to the Safety Committee and monitored ongoing by Safety Committee/Prog Director to assure compliance.
Target Date: 5/30/23
|