INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 9, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia at Sunbury 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:
|
Plan of Correction
|
709.94(d) LICENSURE Project management services
709.94. Project management services.
(d) The project shall develop a written client aftercare policy.
|
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."
|
Plan of Correction
The facility's policy and procedure manual was reviewed May 9 ? 12, 2011 at Gaudenzia's Corporate Office. According to corporate guidelines, no individual facility may change any policy or form to suit facility needs. This citation regarding conflicting policies was reported to the Central Region Director and the CQI Director by the facility Division Director. The CQI Director revised the follow up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia website forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director.
On June 20, 2011 a meeting was held with the Division Director and Administrative Coordinator to review the policy on follow up procedures Gaudenzia developed. A memo was distributed to all staff on June 29, 2011 explaining the procedure to be used effective immediately.
The new policy states; the first follow up will be completed no later than 7 days of discharge on all referred clients who have given written consent. Follow ups will be completed on all other discharged clients within 30 days regardless of discharge status.
Both follow ups will be documented on the same form.
Forms will be forwarded monthly to the Administrative Coordinator to be filed in the proper follow up log/binder. All forms will be reviewed monthly during the administrative meeting with the Clinical Supervisor, Administrative Coordinator and the Division Director. Follow up will be discussed during both clinical meetings and supervisory sessions. Follow up will be completed by designated clinical staff.
|
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.
|
Observations
Based on a review of personnel records on May 9 - 11, 2011, and on June 9, 2011, along with a conversation with the director on June 9, 2011, the clinical supervisor failed to complete a core curriculum training in clinical supervision.
The findings include:
On may 9-11, 2011 and again on June 89, 2011, personnel record #3 (facility clinical supervisor) was reviewed. Employee #3 was hired by the facility on March 13, 2006 and promoted to the position of Clinical Supervisor on June 17, 2010. As of the date of the personnel record review on June 9, 2011, there was no documentation that the Clinical Supervisor had a minimum of two years of supervisory experience , nor was there any documentation showing that employee #3 had completed the core curriculum. prior to being promoted to that position.
The findings wee confirmed by the Facility Director..
|
Plan of Correction
The Clinical Supervisor will attend the next Bureau of Drug and Alcohol Programs Clinical Supervision training. The facility Administrative Coordinator will check weekly in the BDAP system for the next scheduled event. When offered, the Administrative Coordinator will register the Clinical Supervisor. This requirement will be discussed weekly in Administrative meetings until compliancy occurs.
Any Clinical Supervisor promotions will have the Supervisor scheduled for Clinical Supervision training within 6 months of promotion. |