INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2008 through June 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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 July 9, 2008.
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Plan of Correction
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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 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 ensure that a voluntary and informed consent for the disclosure of information was obtained from the client in nine out of ten client records reviewed, #1, 2, 4, 5, 6, 7, 8, 9 and 10. The specific information disclosed exceeded that allowed by 4 Pa. Code 255.5. Specifically, the information to be disclosed to the insurance company, the legal system and the attorney included "treatment recommendations."
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Plan of Correction
Treatment recommendations will be changed to level of care for compliance by the Program Supervisor on June 26, 2008. This will be monitored by the Program Director. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed, #8.
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Plan of Correction
Program Supervisor is responsible for training all clinical personnel regarding involuntary termination. All discharged charts will be reviewed in UR for this letter to the client by the Administrative Coordinator. The training will occur on Friday, June 26, 2008. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to inform the client of his/her right to request a reconsideration of a decision terminating treatment in one of one applicable client record reviewed, #8.
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Plan of Correction
Program Supervisor is responsible for training clinical personnel regarding involuntary termination. The Administrative Coordinator will review discharges for utilization review for this aspect of non-compliant client discharge. The training will occur on Friday, June 26, 2008. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document a complete aftercare plan in two of three applicable client records reviewed, #10 and 12. The aftercare goals were not individualized and did not include specific time frames.
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Plan of Correction
Training for aftercare plans will be completed by the Program Supervisor regarding individual goals and specific timeframes on June 26, 2008 in clinical meeting. Aftercare plans will be reviewed and monitored by the utilization review process on a monthly basis by the aftercare for compliance. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the facility's client census and staff interview, the facility failed to limit active clients to the authorized maximum capacity. The facility's authorized maximum capacity is 150 clients, however the actual capacity on the dates of inspection was 162 clients.
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Plan of Correction
Action was taken to request an increase in capacity and the request was approved on 6/10/08. Administrative Coordinator will be responsible to monitor capacity. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel records and staff interview, the facility failed to document an assessment of staff training needs in three of nine records reviewed, #2, 8 and 9.
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Plan of Correction
Training needs assessment at hire and annually will be completed for all personnel by the Program Supervisor. Documentation will be sent to the Central Region Office to be processed to the Corporate Office. This will be monitored by Program Supervisor, Administrative Coordinator and Central Region Office. |
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 and staff interview, the facility failed to document an individual training plan in three of nine personnel records reviewed, #2, 8 and 9.
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Plan of Correction
Individual training plans will be completed at hire and annually by the appropriate supervisor. This process is completed at the end of the calendar year and sent to the Central Region Office for processing to the Corporate Office. This will be monitored by the Program Director, Program Supervisor, Administrative Coordinator and Central Region Office. |
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
Based on a review of personnel records and staff interview, the facility failed to provide documentation of at least twelve annual training hours for the facility director. There were zero documented training hours for the facility director.
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Plan of Correction
The facility director will receive 12 hours of training annually. The training hours will be submitted to the Central Region Office of Gaudenzia fo review and submission to the Gaudenzia Corporate Office. This will be monitored by the Central Region Office. |
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 a review of personnel records and staff interview, the facility failed to provide documentation of at least twenty-five annual training hours for each counselor. Employee #5 only had 19.5 documented annual training hours.
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Plan of Correction
The counselor will receive 25 hours annually of training. The training hours will be submitted to the Central Region Office of Gaudenzia for review and submission to the Corporate Office of Gaudenzia. This will be monitored by the Program Supervisor, Counselor and Central Region Office. |