INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudeniza Inc. 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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704.7(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 a review of five personnel records, the facility failed to ensure each counselor met the required experience necessary for the degree they possessed in one of two applicable records reviewed.
Employee #5 was hired as a counselor one March 1, 2021 with a bachelor ' s degree, but did not have the 1 year of clinical experience required.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director has completed a full review of all staff qualifications.
Employee #5 was found to have at least 1 year of counseling experience and has updated her resume to reflect same. A copy of the updated resume will be sent to DDAP on 08/09/21.
In an effort to ensure ongoing compliance all new counselor staff resumes will be reviewed by the Director prior to hire, as per Gaudenzia policy.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of five personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that two employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #2 was hired as the facility director on January 27, 2020 and was due to have the communicable disease trainings no later than January 27, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #3 was hired as a clinical supervisor on December 23, 2019 and was due to have the communicable disease trainings no later than December 23, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director has completed a full review of all staff training requirements regarding Communicable Disease.
Employee #2: DDAP Basic HIV 1 & 2 training completed on 2/19/2021; TB/STD Completed on 10/28/20.
Employee #3: Has notified DDAP regarding his trainings and is scheduled for Basic HIV 1 & 2 for August 24 & 25, 2021. Employee will continue to register for trainings and complete them when they are available.
Program Director and/or Clinical Supervisor will monitor Annual Staff Training Grid monthly to reinforce the DDAP training requirements for staff members to complete within 1 year of employment. Program Director will ensure monitoring and scheduling of trainings. The Clinical Supervisor will review non-compliance of trainings with staff and this will become a part of their clinical supervision.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records, the facility failed to ensure that all informed and voluntary consent forms included the specific information to be disclosed in one client record reviewed.
Client #2 was admitted on June 17, 2021 and was an active client as of the date of the inspection. An informed and voluntary consent form was signed and dated on June 17, 2021 to the funding source that failed to include the specific information to be disclosed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review Confidentiality and Releases of Information with all staff during staff in-service by 07/30/2021.
In addition, the Program Director and Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and report findings to the Program Director.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records, the facility failed to ensure that all informed and voluntary consent forms included the purpose of disclosure in one client record reviewed.
Client #2 was admitted on June 17, 2021 and was an active client as of the date of the inspection. An informed and voluntary consent form was signed and dated on June 17, 2021 to the funding source that failed to include the purpose of disclosure.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review Confidentiality and Releases of Information with all staff during staff in-service by 07/30/2021.
In addition, the Program Director and Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and report findings to the Program Director
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709.28 (c) (5) 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. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of seven client records, the facility failed to ensure that all informed and voluntary consent forms included the dated signature of a witness in one client record reviewed.
Client #2 was admitted on June 17, 2021 and was an active client as of the date of the inspection. An informed and voluntary consent form was signed and dated on June 17, 2021 to the funding source that failed to include the dated signature of a witness.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review Confidentiality and Releases of Information with all staff during staff in-service by 07/30/2021.
In addition, the Program Director and Clinical Supervisor will monitor confidential releases of information during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and report findings to the Program Director
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of seven client records, the facility failed to ensure client records contained follow up information in three of three applicable records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor will review Follow Consents and Documentation with all staff during staff in-service by 07/30/2021.
In addition, the Program Director and Clinical Supervisor will monitor Follow up Consents and Documentation during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor confidentiality and releases of information during quarterly CQI file audits and report findings to the Program Director
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by clients at the project is an integral part of their treatment and rehabilitation plan in all seven records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Clinical Supervisor will review work therapy and documentation of work therapy as part of the treatment plan with all clinical staff during staff in-service by 07/30/2021.
The treatment plans of all client's currently active, who are engaged in chores/work therapy, will be updated to reflect work therapy as an integral part of the individual's treatment.
To ensure continued compliance the Program Director and Clinical Supervisor will monitor treatment plans during monthly file audits and address discrepancies during staff supervisions.
The CQI department will monitor treatment plans during quarterly CQI file audits and report findings to the Program Director
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