INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of facility records provided as part of the presubmission process, and based on staff interviews conducted during the on-site inspection, the facility failed to acquired all of the required training for its staff. Staff Person #3 was hired as a counselor for the facility on 05/16/2017, and was promoted to a clinical supervisor on 07/24/2017. Staff Person #3 at the time of the staff person's promotion to clinical supervisor had not functioned as a supervisor in the provision of clinical services for 2 years, but at the time of the on-site inspection still had not completed the Department's core curriculum in clinical supervision. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to ensure that it obtained documentation that it notified all clients of their rights. The records for clients # 1, 2, 3, 4, 5, 6, and 7 did not have documentation that the clients had been notified of the their rights. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |