INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on May 24, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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704.11(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 personnel records, the facility failed to document an individual training plan in accordance with facility policy in three of five records.
The findings include:
The project policy states: " In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year. "
On May 9, 2012, personnel records for employees # 1, 2, 3, 4 and 5 were reviewed. The project failed to develop an individual training plan annually in accordance with policy for personnel #s 1, 2 and 4.
Employee # 1 has been the Project Director since 1988. The facility failed to document an individual training plan in January for employee # 1. Employee # 1 ' s record did not contain a training plan.
Employee # 2 has been the Facility Director since 2008. The facility failed to document an individual training plan in January for employee # 2. Employee # 2 ' s record did not contain a training plan.
Employee # 4 has been a counselor since 2011. The facility failed to document an individual training plan in January for employee # 4. The training plan in employee # 4 ' s record was dated 2/22/12.
The findings were reviewed with the human resources staff.
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Plan of Correction
"The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all Managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file." Individual Training Plans will be completed for all employees by January 31st, 2013 as per our policy. |
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, the facility failed to document at least 25 clock hours of training annually in one out of two records reviewed.
The findings include:
On May 9, 2012, two personnel records identified as a counselor during the 2011 training year were reviewed for documentation of 25 clock hours of training. The facility did not document 25 hours of training for the 2011 training year in personnel record # 5.
Personnel #5 was hired on 9/13/10. Personnel # 5's record contained training certificates for only 6 hours of training during the 2011 training year.
The findings were reviewed with the human resources staff.
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Plan of Correction
Personnel #5 has a training plan developed for the year 2012 which will identify 25 hours of training that will be completed as per the state regulation. The Clinical Supervisor will ensure that all required traing hours are completed by December of 2012. The Program Director will oversee that Clinical Supervisor in this task. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document that fire extinguisher training was provided upon employment in one out of one personnel records.
The findings include:
On May 9, 2012, one personnel record requiring documentation of fire extinguisher training upon employment was reviewed.
Personnel # 4 was hired on 1/18/11, but verification of the fire extinguisher training was not documented at the time of review.
The findings were reviewed with the human resources staff.
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Plan of Correction
Clinical Supervisor will ensure that all staff recieve Fire Safety and Fire Extinguisher Training during their orientation to the facility upon their hire. The Program Director will oversee and ensure that when the employee's personnel chart is created, this documentation is present in the chart for all new staff. Personnel #4 has recieved this training and the documentation is currently in his chart. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to document that all personnel are trained to perform assigned task during emergencies in one out of one personnel records.
The findings include:
On May 9, 2012, one personnel record was reviewed for documentation of emergency training. The facility did not document that emergency training was provided upon employment in personnel record # 4.
Personnel # 4 was hired on 1/18/11, but verification of this training was not documented at the time of review.
The findings were reviewed with the human resources staff.
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Plan of Correction
Clinical Supervisor will ensure that all staff recieve Fire Safety and Fire Extinguisher Training during their orientation to the facility upon their hire. The Program Director will oversee and ensure that when the employee's personnel chart is created, this documentation is present in the chart for all new staff. Personnel #4 has recieved this training and the documentation is currently in his chart. |
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 upon a review of the project ' s Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, ' Intake Process/Paperwork " Treatment Plan included the following language:
" The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) within 3-5 client days residential... "
The policy titled, " Individual Treatment Plan " Individual Treatment and Rehabilitation Plan included the following language:
" Completion of the treatment plan will be noted in the counselor ' s progress note for that day of service, within 3 days of admission (residential)... "
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, " Individual Treatment Plan " Individual Treatment and Rehabilitation Plan included the following language:
" An individual treatment and rehabilitation plan will be developed with each client after the completion of the client ' s psychosocial evaluation. "
The policy titled, " Intake Process/Paperwork " Treatment Plan included the following language:
" Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ... " The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment..... "
The policy titled, " Intake Process/Paperwork " Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, " Individual Treatment Plan " Individual Treatment and Rehabilitation Plan included the following language:
" Completion of the treatment plan will be noted in the counselor's progress note for that day of service... by the third session (outpatient)... "
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
"The relevant policies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis." These policies will be revised and approved by July 31st, 2012. |