INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10 -12, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc.- Crossroads 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 January 17, 2008.
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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 review of personnel records, individual represented by personnel record # 2 does not meet the qualification requirements for clinical supervisor.
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Plan of Correction
A formal staffing exemption was submitted for this employee. If this exemption is not granted then the Division Director for Gaudenzia Crossroads will fill that position with a staff member who does meet staffing regulations. In the interim the Division Director will be responsible for the clinical supervision of this level of care. This will be completed by 3/31/08. |
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.
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Observations
Based on review of personnel records, the individual represented by personnel record # 4 does not meet the qualification requirements for counselor.
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Plan of Correction
Counselor has been transferred to a Counselor Assistant position effective 1/14/08. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on review of the staffing compliance plan the facility is out of compliance with the FTE counselor to client ratios. The counselor represented by personnel record #4 was not included in the ratio because he did not meet the staffing qualifications for the counselor position. The overall ratio for the facility exceeded 8:1.
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Plan of Correction
Division Director will ensure and continue to monitor that staffing ratios are followed. |
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 on review of the staffing compliance plan one counselor's caseload exceeded the limit of 35:1. The counselor represented by personnel record # 11 had a caseload of 39 during the licensing inspection. Outpatient counselors may only have a caseload of up to 35 active clients at any given time.
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Plan of Correction
Division Director will ensure and monitor that staffing ratios are followed. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on review of client records, the facility failed to document complete progress notes in four of four records reviewed, # 2, 4, 5, and 6. The group progress notes did not include a data section that was individualized per group by the counselor that included observation and information about the client and the assessment did not include the counselor's analysis of and conclusions regarding the client's interactions during the group sessions. The inspector was unable to determine if the group notes were clinical/therapeutic or if they were educational.
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Plan of Correction
Division Director will train all clinical staff on the appropriate way to complete clinical group notes. This clinical staff training will be held on or before 2/29/08. Program Directors and Supervisors will monitor compliance during the agency's monthly Quality Improvement program. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of client records the facility failed to document a complete personal history in three out of three client records reviewed, # 1, 2, and 3. Personal histories did not include pertinent personal data on family, educational, and sexual histories. Personal history forms would ask for more detailed information then was documented on the histories.
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Plan of Correction
Program Supervisor will train staff on personal histories and the need to have all areas addressed fully which include data on family, educational, and sexual histories. She will monitor compliance during monthly Quality Improvement process. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on review of client records, the facility failed to document complete progress notes in three of three records reviewed, # 1, 2, and 3. The group progress notes did not include a data section that was individualized per group by the counselor that included observation and information about the client and the assessment did not include the counselor's analysis of and conclusions regarding the client's interactions during the group sessions. The nature of the notes made it difficult to determine if the group whether the notes were clinical/therapeutic or educational.
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Plan of Correction
Division Director will train all clinical staff on the appropriate way to complete clinical group notes. This clinical staff training will be held on or before 2/29/08. Program Directors and Supervisors will monitor compliance during the agency's monthly Quality Improvement program. |