INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6 & 7, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia 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 and a plan of correction is due on March 18, 2008.
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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 upon a review of training records on February 6 & 7, 2008, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually.
Employee #4 completed 21.5 hours of the required 25 hours.
Employee #5 completed 15.5 hours of the required 25 hours.
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Plan of Correction
Program Supervisor will be responsible for developing and maintaining a system which holds counselors accountable for their training hours. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based upon a review of the staffing form, client case loads and hours worked by the clinicians during the licensing inspection of February 7, 2008, the facility failed to ensure that the counselor caseload did not exceed 35 active clients. The overall ratio was 41:1. The individual caseloads were as follows:
Employee #3 (Clinical Supervisor) 46:1
Employee #4 (Counselor III) 38:1
Employee #5 (Counselor II) 53:1
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Plan of Correction
Advertising for the positions was completed by 2/29/08. Interviewing by the Program Supervisor has occurred for all three positions. Two individuals have been contracted to provide services. The Program Supervisor is responsible for hiring, training and adjusting census to meet the standards. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based upon a review of the facility's fire drill log on February 7, 2008, the facility failed to conduct unannounced fire drills at least once per month. The facility failed to conduct a drill in December of 2007.
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Plan of Correction
The Division Director will hold the administrative personnel responsible for holding the fire drills monthly. Failure to comply will result in corrective action. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon a review of facility documents and an interview with facility staff on February 6 & 7, 2008, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The audit for the 2006-2007 fiscal year had not yet been completed.
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Plan of Correction
Grant-Thornton completed the audit of Gaudenzia Inc December 2007. The Board of Directors December minutes reflect the audit completion as well as the Board review of the audit findings. |
709.93(a)(2) LICENSURE Client records
709.93. 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 upon a review of client records on February 6 & 7, 2008, the facility failed provide a complete medication record to include the medication, dosage and frequency of use, in four of four client records reviewed, records #3, 4, 6 & 8. Client record #2 lacked the name of one of the medications and lacked the dosage for another medication. Client record #4 lacked the dosage for two of the listed medications and did not clearly indicate the frequency in which the medications were to be taken.
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Plan of Correction
Program Supervisor will train clinical personnel regarding medication records and the importance of same. Medical records will be the focus of monthly QI completed by the Program Supervisor. This is an audit of the client records. |