INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 12, 2009 licensure renewal inspection. The follow-up inspection was conducted on November 13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 December 17, 2009.
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Plan of Correction
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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 of 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.
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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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 client records the facility failed to follow their written plan for the coordination of client treatment and rehabilitation services in two of four 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's policy and procedures directed that the initial treatment plan be documented within five days of admission with updated every 30 days. The facility failed to follow their procedure as they are currently completing a preliminary treatment plan at admission and a comprehensive plan within 14 days of admission. The first update is being completed at 30 days with updates every 30 days.
On November 13, 2009 four open case files were reviewed for compliance with preliminary treatment plans, comprehensive treatment plans and treatment plan updates. Two out of four records ( # 2 and 3) did not have documented treatment plans within the aforementioned.
time frames.
Client record #2 failed to have a treatment plan update documented that was due on 11/11/2009.
Client record # 3 failed to have a comprehensive treatment plan documented that was due on 10/28/2009.
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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. Program Director will review this procedure with clinical staff and Clinical Supervisor and will discuss and bring an example of an initial treatment plan and a comprehensive treatment plan to better conduct a staff training no later than 12/30/09.
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 in turn give treatment plans to the Program Director for final approval.
Person Responsible: Clinical Supervisor
Person Responsible for the 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 client records the specific information disclosed to the funding source exceeded 4 Pa. Code, Subsection 255.5(b) in that the consent to release information form included the social history in 4 out of 4 client records reviewed.
Findings:
Four client records were reviewed on November 13, 2009. An informed and voluntary consent to include the specific information disclosed was required in four client records. The facility failed to obtain and informed voluntary consent to include the specific information disclosed in client records #1, 2, 3,and 4.
In client records #1, 2, 3, and 4 consents to the funding source exceeded Pa Code 255.5 as they included "social history" in the specific information to be disclosed. This disclosure exceeded 4 Pa. Code, Subsection 255.5(b) regarding information to made available through involuntary consent.
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Plan of Correction
The consent to the funding source that has "social history" marked will no longer include "social history" so as not to exceed 4 Pa. Code, Subsection 255.5(b).
This facility will document an informed and voluntary consent for every client coming into the program which includes the specific information to be disclosed.
To prevent this from recurring, the informed consent to treatment will be reviewed and changed as needed and all administrative and clinical staff will be trained on how to correctly fill out a release of information form and what is appropriate for each source.
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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