INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20 through August 21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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 September 24, 2007.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The facility failed to document the direct observation portion of close supervision for employee #9 from July 2, 2007 until through August 20, 2007.
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Plan of Correction
Project was not in compliance with the standard due to agencies failure to correctly document direct supervision. Documentation of direct supervision of counselor assistants will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to utilize alternate exit routes during the fire drills conducted from October 2006 through to July 2007.
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Plan of Correction
The facility will utilize and document alternate exit routes during fire drills. The Program Director is the person responsible. |
709.22(e)(1) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(1) Activities and accomplishments of the preceding year.
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Observations
Based on a review of administrative documentation,the facility failed to document a statement of activities and accomplishments for the facility in the annual report.
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Plan of Correction
The annual report for the FY'07 will be printed and available for the current FY and every year thereafter and will include activities and accomplishments for the pervious FY. The Director of Development is the person responsible. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation, the facility failed to document available resources and time frames for achievement of the stated goals and objectives.
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Plan of Correction
Executive staff who are responsible for specific goal areas will develop and revise plans in specific goal areas in consultation with their respective Board Committees and available resources for approval at the September Board meeting and every September thereafter. Executive Staff is responsible. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
The facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
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Plan of Correction
Project was not in compliance with the standard due to the current agreements omission of language specifying 24 hour emergency medical coverage. A written agreement with a licensed hospital for 24 hour emergency medical coverage will be available September 2007 and will be renewed every two years thereafter. The Program Director is the person responsible. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to comply with the restriction imposed at 4 Pa. Code, Subsection 255.5 (b) by allowing discharge summaries to be released to parole and probation officers and the Department of Corrections in four of twelve records reviewed, #2, 3, 10 and 11. A consent to release form to the client's funding source was signed by both the client and staff personnel but the specific information to be released was left blank in one of twelve records reviewed, #5.
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Plan of Correction
Project was not in compliance with the standard due to new untrained staff. An in-service facilitated by Division Director, will be held Friday, October 12, 2007 to address Confidentiality. Ongoing training will be provided by the Gaudenzia Training Institute. Consent to release information documents will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of treatment in seven of twelve records reviewed, #1, 3, 4, 9, 10, 11 and 12.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems and new untrained staff. An in-service facilitated by Supervisors, will be held Friday, November 9, 2007 to address Treatment and rehabilitation service plan documentation of type and frequency of treatment and rehabilitation services. Ongoing training will be provided by the Gaudenzia Training Institute. Treatment and rehabilitation service plans will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services in six of twelve records reviewed, #1, 2, 3, 6, 9 and 11.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems and new untrained staff. An in-service facilitated by Supervisors, will be held November 9, 2007 to address Treatment and rehabilitation service plan proposed type of support services. Ongoing training will be provided by the Gaudenzia Training Institute. Treatment and rehabilitation service plan support services will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |
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
Based on a review of client records, the facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in five of twelve client records reviewed, #1, 8, 10, 11 and 12. Treatment plan updates were not completed within 60 days as required in five of twelve records reviewed, #3, 4, 5, 9, and 12.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems and new untrained staff. An in-service facilitated by Supervisors, will be held Friday, November 9, 2007 to address Treatment and rehabilitation service plan update review of progress on previously stated goals. Ongoing training will be provided by the Gaudenzia Training Institute. Treatment and rehabilitation service plan updates will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |