INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11 and 12, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Vantage House 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 15, 2009.
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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
Based on a review of supervision notes, the facility failed to document close supervision in one of one counselor assistant personnel records reviewed.
Findings:
One counselor assistant's record was reviewed on May 5, 2009 and supervision documentation was reviewed on June 11, 2009. Close supervision of one hour direct observation and formal documentation of one hour of supervision per week was required for one personnel record, #6. Employee #6 was hired for the position of counselor assistant on 7/21/08. The facility documented weekly supervision notes from 7/21/08 through 4/21/09 but did not document one hour of direct observation to be included in supervision.
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Plan of Correction
Effective immediately, all supervision of counselor assistant's will have documented weekly supervision notes that will include documentation of one hour of direct observation per week.
To prevent this from recurring, the Program Director will review the status of all counselor assistant's with the Clinical Supervisor to include proper documentation of supervision. This will occur on a monthly basis.
Person Responsible: Clinical Supervisor
Person Responsible for the Monitoring: Program Director
Full compliance: 6/30/09
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, CPR certification and first aid training records, the facility failed to ensure that at least one person trained in CPR and first aid was onsite during the project's hours of operation.
Findings:
Personnel, CPR certification and first aid training records and the work schedule for the prior four weeks were reviewed on May 5 and June 11, 2009. Based on the documentation provided by the facility, the facility failed to ensure that at least one person trained in CPR was onsite during the project's hours of operation for the following dates: 5/10/09 for the 3:30 to 11:30 PM shift, 5/11/09 from 9:00 to 11:00 PM, 5/12/09 from 7:00 to 8:30 AM, 5/14/09 from 7:00 to 8:30 AM, 5/18/09 from 7:00 to 8:30 AM, 5/19/09 from 9:00 to 11:00 PM, 5/24/09 from 3:00 to 3:30 PM, 5/28/09 from 4:30 to 11:00 PM, 5/29/09 from 11:30 PM to 7:00 AM, 5/30/09 from 11:30 PM to 7:00 AM, 6/1/09 from 7:30 to 8:30 AM, 6/2/09 from 7:00 to 8:30 AM and 6/5/09 from 9:00 to 11:00 PM.
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Plan of Correction
Plan of Correction:
As per licensing regulations, staff members will be trained in CPR/First Aid so as at least one person trained in CPR/First Aide will be trained on each shift.
As of 6/30/2009, all shifts are covered by a staff member who is CPR/First Aid certified.
To prevent this from recurring, all necessary staff will be trained in CPR/First Aid. In addition, a monthly training report will be handed in to the Director and to QI regarding upcoming CPR recertifications needed. Reporting this information monthly will allow us the time needed to recertify without being out of compliance.
Person Responsible: Administrative Coordinator
Person Responsible for the Monitoring: Program Director
Full compliance: 8/22/09
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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 seven training records, two which were for counselors, the facility failed to document that one of two counselors completed at least 25 clock hours of training during the training year.
Findings:
Seven training records were reviewed on May 5 and June 11, 2009. At least 25 clock hours of training for the 2008 training year was required for two employees. The facility failed to document at least 25 clock hours of training for the 2008 training year for employee #5.
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Plan of Correction
Effective immediately, all staff will receive the minimum training hours as required by the Department of Health within each calendar year. These training hours will be accurately documented.
To prevent this from recurring, the training report will be reviewed monthly by the Program Director and will also be reported on and turned into QI monthly. The Director will have immediate access to any staff who is behind in their training.
Person Responsible: Administrative Coordinator
Person Responsible for the Monitoring: Program Director
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of the policy and procedure manual, and eight client records, the facility failed to follow the written plan for the coordination of client treatment and rehabilitation services in eight of eight records reviewed.
Findings:
The policy and procedure manual was reviewed on May 5 and June 11, 2009.
The facility failed to follow the written plan for the coordination of client treatment and rehabilitation services. The facility policy and procedures manual directs that the initial treatment plan is completed within five days of admission with updates every 30 days. The facility is completing a preliminary treatment plan at admission and a comprehensive treatment plan within 14 days of admission, the first update at 30 days and then an update every 30 days.
Client records #1-8 all lacked an initial treatment plan completed within 5 days from the date of admission.
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Plan of Correction
Effective immediately, the facility will follow the written plan for the coordination of client treatment and rehabilitation services. The facility will follow the facility policy and procedures manual and complete an initial treatment plan within five days of admission and updates every 30 days. Clinical Supervisor will review this procedure with clinical staff and conduct a staff training no later than 6/30/09.
To prevent this from recurring, the Clinical Supervisor will review clinical paperwork weekly to ensure that the treatment plan is written properly and the written plan is followed. The Clinical Supervisor will report any problems to the Program Director.
Person Responsible: Clinical Supervisor
Person Responsible for the Monitoring: Program Director
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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
Based on a review of the Letters of Agreement, the facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage.
Findings:
The Letters of Agreement were reviewed on June 12, 2009. The facility failed to document a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage.
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Plan of Correction
Effective immediately, the Letter of Agreement with a licensed hospital or physician for 24 hour emergency psychiatric and medical coverage will be rewritten to say "24 hour emergency psychiatric and medical coverage".
Person Responsible: Administrative Coordinator
Person Responsible for the Monitoring: Program Director
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709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of eight client records reviewed.
Findings:
Eight client records were reviewed on June 11 and 12, 2009. An informed and voluntary consent from the client was required in eight client records. The facility failed to document an informed and voluntary consent from the client for the disclosure of information in client records #1, 2 and 3. The facility had the clients sign a consent generated by the Office of the Attorney General for Pennsylvania which did not include an expiration date, did not include specific information to be released and included the statement that the information released was subject to re-disclosure.
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Plan of Correction
This facility will document an informed and voluntary consent for every client coming into the program.
The consent generated by the Office of the Attorney General for Pennsylvania will be discarded immediately due to lack of an expiration date and having the statement that the information released was subject to re-disclosure.
In addition, all current clinical files will have a new consent with an expiration date signed and put in the client's file.
To prevent this from recurring, all adminisitrative and clinical staff will be trained in the correct way to fill out an informed and voluntary consent.
Charts are reviewed monthly by the Clinical Supervisor, with any problems reported to QI.
Person Responsible: Clinical Supervisor
Person Responsible for monitoring: Program Director
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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 eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the specific information disclosed in six of eight client records.
Findings:
Eight client records were reviewed on June 11 and 12, 2009. An informed and voluntary consent to include the specific information disclosed was required in eight client records. The facility failed to obtain and informed and voluntary consent to include the specific information disclosed in client records #1, 3, 4, 5, 6 and 7.
In client records #1, 5, 6 and 7, consents to the funding source exceeded Pa Code 255.5 as they included "social history" in the specific information to be disclosed.
In client record #3, consents to release information to the emergency contact, Common Ground, two county drug and alcohol agencies and a county assistance office did not document any specific information to be released.
In client record #4, a consent to a county drug and alcohol agency, with no purpose listed, exceeded Pa Code 255.5 as the specific information to be released included "social history".
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Plan of Correction
A confidentiality training will be conducted to all clinical and administrative staff that handle release of information forms. This training will include specifics on what can or cannot be disclosed based on Pa Code 255.5., as well as an overview of how a release of information form should be filled out. This training will take place no later than 7/15/2009.
Effective immediately, the facility will obtain from all clients an informed and voluntary consent for the disclosure of the information contained in the client record to include the specific information disclosed in each chart.
To prevent this from recurring, the Clinical Supervisor will review confidentiality forms prior to their being filed in the charts and report any problems to the Program Director for correction.
Person Responsible: Clinical Supervisor
Person responsible for the Monitoring: Program Director
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of eight client records, the facility failed to document an individual treatment and rehabilitation plan in six of eight client records reviewed.
Findings:
Eight client records were reviewed on June 11 and 12, 2009. An individual treatment and rehabilitation plan was required in six of eight client records reviewed. The facility failed to document an individualized treatment plan in client records #1, 2, 3, 4, 5 and 6. The goals and the action steps were identical in the treatment plans for all six clients.
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Plan of Correction
Effective immediately,
the facility will document an individualized treatment plan in all client records to include individualized treatment plan goals on the initial treatment plan.
Clinical Supervisor will review this procedure and conduct a training with clinical staff no later than 6/30/09.
To prevent this from recurring, the clinical supervisor will review all treatment plans prior to their filing in the charts. This will be done on a monthly basis and will be reported in QI.
Person Responsible: Clinical Supervisor
Person responsible for the Monitoring: Program Director
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