INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia Willow Gove/Dresher 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to provide 12 clock hours for employee # 1.Employee # 1 was hired on January 19, 1973 and began current position on May 16, 2017. There was no documentation of 12 clock hours of annual training in the employee record.
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Plan of Correction
Corporate office has documented verification of 48 hrs of clocked training for Employee #1.
Documented hours have been forwarded are available on site.
Going forward Clinical Supervisor will ensure as soon as Employee #1 completes training hours that his Training Hours and Certificates will be available onsite at the facility.This process will be monitored by The Program Director .
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709.28 (c) 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.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 in 7 of 7 records reviewed.7 records reviewed included verbiage on the consent to release forms stating verbatim; "criminal justice system clients who have agreed to enter treatment in lieu of prosecution or punishment may not revoke their consent that allows the court, parole, or other criminal justice agency from monitoring their progress in treatment" in client records # 1, 2, 3, 4, 5, 6, and 7.Client # 1 was admitted on July 12, 2018 and was still an active client at the time of the inspection. Consent to release forms signed and dated on July 12, 2018 also had expiration dates of July 12, 2018. There were correspondence with outside agencies made after the expiration date on the consents.
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Plan of Correction
Clinical Supervisor will provide a seminar discussing the limits established by 4 Pa. Code 255.5.
Going forward all releases of information will include the person's right to verbally revoke their consent. The verbiage in question has been removed from all consents on site and any unfilled consents will be shredded in order to ensure they cannot be used moving forward.
Client #1 will be provided new consents for signature.
This process will be overseen by the Program Director and completed by 02/19/2019. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to provide treatment plan updates at least every 60 days in 4 of 7 records reviewed.Client # 1 was admitted on July 12, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on August 16, 2018 and an update was performed on October 11, 2018. The next update was due no later than December 11, 2018.Client # 3 was admitted on August 15, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on September 14, 2018 and an update was performed on October 15, 2018. The next update was due no later than December 15, 2018.Client # 4 was admitted on October 15, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on October 15, 2018. The next update was due no later than December 15, 2018. Client # 6 was admitted on February 28, 2018 and was discharged on December 5, 2018. A comprehensive treatment plan was developed with the client on April 25, 2018 and an update was performed on August 15, 2018. The next update was due no later than October 15, 2018.
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Plan of Correction
Clinical Supervisor will conduct a seminar detailing the requirements of updated treatment plans being necessary at least every 30 days for an IOP client and 60 days for OP clients.
This seminar will occur on 2/14/19.
This process will be monitored by the Program Director. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure counseling services are provided according to the individual treatment and rehabilitation plan in 4 of 7 records reviewed.Client # 1 was admitted on July 12, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on August 16, 2018 that indicated 1 individual and 2 group counseling sessions per week. The chart's record of service and progress notes indicated that the client did not receive:Individual sessions the weeks of August 26-September 1, September 2-8, October 14-20, 21-27, November 18-23, 25-December 1 and no other sessions after the last documented session on December 13, 2018. 2 Group sessions the weeks of August 12-18, 26-September 1, 2-8, 9-15, 23-29, 30-October 6, 7-13, 14-20, 21-27, 28-November 3, 5-7, 18-24, 25- December 1, 2-8, 9-14, 16-22 and no other sessions after the last documented session on December 17, 2018.Client # 3 was admitted on August 15, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on September 14, 2018 that indicated individual and group counseling sessions weekly. The chart's record of service and progress notes indicated that the client did not receive:Individual sessions the weeks of September 30-October 20, November 18-24 and no other sessions after the last documented session on November 28, 2018.Client # 4 was admitted on October 15, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on October 15, 2018 that indicated individual and group counseling sessions weekly. The chart's record of service and progress notes indicated that the client did not receive:Individual sessions the weeks of November 4-10, 11-17, 25-December 1, 2-8 and no other sessions after the last documented session on December 10, 2018.No group sessions the weeks of October 21-27, November 11-17, December 16-22, 23-29.Client # 5 was admitted on July 17, 2018 and was discharged on December 6, 2018. A comprehensive treatment plan was developed with the client on August 7, 2018 that indicated 1 individual and 2 group counseling sessions per week. The chart's record of service and progress notes indicated that the client did not receive:Individual sessions August 26-September 1, October 21-27, 28- November 3, 4-10, 18-24, 28- December 1 and no other sessions after the last documented session on December 6, 2018.No group sessions the weeks of August 19-25, September 2-8, October 7-13, 14-20, 21-27, November 4-17 and only 1 session the weeks of August 5-11, October 14-20, 28- November 3, 18-24.
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Plan of Correction
Clinical Supervisor will conduct a seminar on proper documentation of group and individual sessions in accordance to their individual treatment plans. Supervisor will review proper documentation of show and no show notes within EHR. Seminar to occur 2/21/19. Supervisor will review documentation in AVATAR once weekly to ensure notes are completed and documented correctly. If individual is a no show counselor will complete a collateral note indicating the missed session.
This process will be overseen by the Program Director. |