INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 14, 2009 licensure renewal inspection. The follow-up inspection was conducted on January 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia Outpatient 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
February 21, 2010.
|
Plan of Correction
|
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
Based on the review of administrative staffing documents the facility failed to have a full-time Clinical Supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
Based on a review of the administrative staffing documents and a discussion with the clinical supervisor on February 03, 2010, the facility failed to employ a full-time Clinical Supervisor for every eight full-time counselors or counselor assistants, or both. A review of the administrative staffing documents indicated that the project had 9 full-time equivalent (FTE) counselors and counselor assistants. An interview with the Clinical Supervisor on January 28, 2010 revealed that only one staff person #1 was functioning as a full-time Clinical Supervisor.
|
Plan of Correction
The Program Supervisor ( employee #1) supervises eight counselors. The ninth counselor is temporarily assisting on a part-time basis at HOP but is supervised by the Clinical Supervisor at the satellite office Centro de Vida. This counselor will be resuming fulltime responsibilities at Centro de Vida by May 30, 2010. This will be monitored by the Program Supervisor and the Clinical Supervisor. |
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.
|
Observations
Based on a review of employee records, the facility promoted an individual for a counselor position when they did not have the required experience.
The findings include:
Seven employee records were reviewed on January 28, 2010 and February 3, 2010. Employee # 7 was hired as a counselor assistant on August 18, 2008. Employee #7 was promoted on March 11, 2009 to a counselor when they had only seven months of clinical experience, five months short of the 1 year of experience required.
|
Plan of Correction
Employee # 7 was promoted to a counselor position on 8/18/09.
Data reviewed on 3/11/09 was a 6 month evaluation which indicates job title as Counselor Assistant. Beginning 1/28/10, the Program Supervisor will ensure all counselors meet the required experience before they are considered for a promotion.
|
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a interview with the supervisor the facility failed to get approval from the Department of Health to increase their capacity.
The findings include:
An interview was conducted with the facility supervisor on January 28,2010 at 11:00 AM. The supervisor disclosed that the current client capacity was 216. The facility failed to get authorization to exceed their licensed capacity of 190.
|
Plan of Correction
Program Supervisor will review current census beginning March 1, 2010 and discharge those clients that are not attending and/or the supervisor will begin referring clients to other providers until capacity requirements are met. Program Supervisor will monitor client census to ensure it does not exceed capacity limitations on a weekly basis. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
Based on an inspection of the facility ' s physical plant, the facility failed to secure all client records within locked storage area solely for client records.
Findings:
An inspection of the facility ' s physical plant was conducted on January 28, 2010 at approximately 2:00 PM.. Discharged client records were stored in boxes in three separate locked rooms in the basement. The facility failed to ensure that records were kept in rooms that were used solely for the purpose of record storage. Other non-record related items were also stored in these rooms.
|
Plan of Correction
The Administrative Coordinator will ensure all discharged client records are stored in one room. The Administrative Coordinator will also remove all non-record items from the record storage room by 3/1/10 |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow-up information in one of three client records.
Findings:
Three client records were reviewed on January 28, 2010 at 1:00 PM. Follow-up information was required in three client records. The facility did not document follow-up information within 30 days after discharge, as stated in the project's policy and procedure's manual, in client record # 5.
Record # 5 was discharged 9/18/09, but follow-up information was not documented at time of inspection.
|
Plan of Correction
Follow up per policy and procedure will be fully implemented by the Program Supervisor and Administrative Coordinator. Completion of the follow up will be monitored monthly in the Administrative meeting for policy compliance and documented in the minutes. |