INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6, 2011 through June 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 personnel records and a discussion with the virtual learning manager and the facility director, the facility failed to ensure each counselor hired met the qualifications.
The findings include:
A new staff person with a qualifying bachelor's degree was hired on 9/13/10 as a counselor, employee # 5. However, employee # 5 did not have the required one year of clinical experience. This was verified by reviewing her resume.
This was also confirmed during a discussion with the facility director.
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Plan of Correction
Employee #5 was reassigned as a Counselor Assistant and a new job description was signed accordingly.
The Program Supervisor will continue to provide weekly close supervison as required until the employee has obtained at least one year clinical experience as cited in the standard.
The Program Director will monitor ongoing conformance with the standard and assure that any future new hires meet the qualifications outlined in the regulation.
Target Date of Resoultion: 6/30/2011, Completed
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and a discussion with the virtual learning manager, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of two personnel records.
The findings include:
Six personnel records were reviewed at the facility's corporate office on May 9, 2011 through May 11, 2011. Two of those six personnel records were reviewed for fire extinguisher training because they were new hires. Fire extinguisher training was documented late in one of the two personnel records, #6.
Employee # 6 was hired on 3/14/11. Fire extinguisher training was documented as being completed on 4/7/11 in personnel record #6. The training was not provided upon employment.
These findings were confirmed with the virtual learning manager.
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Plan of Correction
All staff including employee #6 were trained on fire safety including but not limited to the use of fire extinguishers.
The Program Supervisor and Director will monitor ongoing conformance and assure that all future new hires continue to recieve fire extinguisher training within the initial week of employment as required by regulation and that such training is properly documented.
The Program Supervisor and Director will verify that all future training documentation is received by the corporate office training institute staff in a timely manner for entry into staff training files at least monthly.
Targeted Resolution Date: 6/30/2011, Completed |
709.64(e) LICENSURE Follow-up policy
709.64. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge. Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt. Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up. In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client's who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder. In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form]. Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder. Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals."
The facility's policy and procedure manual contained a second written policy titled: "FOLLOW UP INFORMATION." This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
A new follow up policy was issued by the corporate office and placed in the program's policy and procedure manual. The former policy was discarded.
The new policy indicates that follow up will be conducted in accordance with the regulation, and shall occur within one week of a referral appointment or within 30 days if no referral appointment was made.
The Program Supervisor and Director shall monitor ongoing conformance, assuring that the facility's follow up activities adhere to the new corporate issued policy.
Target Resolution Date: 6/30/2011, Completed |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
"All clients are followed up after discharge. Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt. Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up. In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder. In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form]. Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder. .Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals."
The facility's policy and procedure manual contained a second written policy titled: "FOLLOW UP INFORMATION." This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
A new follow up policy was issued by the corporate office and placed in the program's policy and procedure manual. The former policy was discarded.
The new policy indicates that follow up will be conducted in accordance with the regulation, and shall occur within one week of a referral appointment or within 30 days if no referral appointment was made.
The Program Supervisor and Director shall monitor ongoing conformance, assuring that the facility's follow up activities adhere to the new corporate issued policy.
Target Resolution Date: 6/30/2011, Completed |