INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22-24, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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 21, 2009.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of eight personnel records, the facility failed to document a written individual training plan in accordance with the facility's policy and procedures, four of eight personnel records.
Findings:
Eight personnel records were reviewed on June 22-24, 2009. Individual training plans were required in eight personnel records. The facility did not document an individual training plan by January 31, as stated in the project ' s policy manual, in personnel records # 2, 3, 4 and 5.
Personnel record #2 training plan documented 3/17/09
Personnel record #3 training plan not dated or signed
Personnel record #4 training plan documented 3/17/09
Personnel record #5 training plan documented 3/20/09
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Plan of Correction
Supervisor(s) and/or Director will create Individual Training Plans annually for each employee by January 31 to meet the regulations. Division Director will ensure the documentation is completed in a timely manner. |
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 eight personnel records, one of which was a counselor's record, the facility failed to document a minimum of 25 hours of training in one of one counselor's personnel record.
Findings:
Eight personnel records were reviewed on June 22-24, 2009. One of the personnel records reviewed was a counselor, requiring documentation of 25 clock hours of training. The facility only had documentation for 6 hours of the required 25 hours for the 2008 training year in personnel record # 7.
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Plan of Correction
Employee # 7 is schedule to complete the 25 clock hours of training that is required annually for 2009. Documentations of trainings will be monitored by supervisors to ensure all trainings are scheduled, attended, and documented (feedback froms) within the required time frames to ensure compliance with this regulation. Copies of certificates and feedback forms will be archived in binders. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant tour, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
Findings:
A tour of the facility ' s physical plant was conducted on June 24, 2009 at approximately 09:00. A group counseling session in progress on the first floor of the facility did not have the shades or windows closed. The counseling session and all participants were observed from outside of the building.
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Plan of Correction
Supervisor(s) will monitor counseling rooms to ensure that the privacy of clients are kept confidential. During the counseling sessions the blinds will be drawn and/or windows closed to protect clients confidentiality according to regulations. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a physical plant tour, and an interview with the facility director, the facility failed to maintain the confidentiality of the client ' s identity.
Findings:
A physical plant inspection was conducted on June 24, 2009 at approximately 09:00. The client sign-in sheet, in the reception area, was observed to contain the first and last names of clients presently at the facility for treatment.
The facility director confirmed the practice of having all client ' s sign the sign-in sheet upon arrival.
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Plan of Correction
Going forward the agency will utilize a sign-in procedure that will not divulge other client's information. Program Director and/or Supervisor(s) will monitor the sign-in procedure. |
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 11 client records, six of which were reviewed for consents to release information, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in four of six client records.
Findings:
Eleven client records were reviewed on June 22-24, 2009. Documentation of informed and voluntary consent was reviewed in six records. The facility did not document informed and voluntary consent for the release of information in client records # 3, 4, 5 and 6.
Client records # 3, 4, 5 and 6 did not document the client ' s right to verbally revoke signed consents for the release of information. The facility documented the client must revoke consents in writing.
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Plan of Correction
Program Supervisor will request modification of existing Consent to Release Information Forms to identify specific (verbally or written) by client. Forms will be reviewed by Continuous Quality Improvement Committee. Going forward old forms will be retrieved and destroyed to assure they won't be used. Supervisors will provide staff with correct consent forms to be utilized in clincal charts. Supervisors will conduct daily audits of clinical charts to ensure correct consent forms has be used for services provided. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of 11 client records, six of which were reviewed for counseling services provided in accordance with the client's individual treatment plans, the facility failed to document counseling services provided according to the individual treatment plan in three of six client records.
Findings:
Eleven client records were reviewed on June 22-24, 2009. Documentation of counseling services provided according to an individual treatment plan was reviewed in six records. The facility did not document counseling according to the treatment plan in client record # 1, 3 and 6.
Record # 1, treatment plan 2/23/09 states group counseling sessions one time weekly, but group sessions were not documented at the time of inspection.
Record # 3, treatment plan 4/22/09 states individual counseling sessions one time weekly, but individual sessions were only documented on 4/22/09, 4/28/09, 5/13/09, 5/18/09 and 6/10/09.
Record # 6, treatment plan 3/17/09 states group counseling sessions two times weekly, but group sessions were only documented 3/17/09, 5/7/09 and 5/13/09.
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Plan of Correction
An in-service facilitated by Supervisor will be held on Friday July 17, 2009 to address Comprehensive Treatment Plan(s) development and counseling services provided that is indicated on treatment Planner. Supervisors will monitor clinical charts to ensure counselors are documenting all schedule individual or group sessions. No show(s) logs will be document upon client failure to show for treatment. |
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.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of five client records.
Eleven client records were reviewed on June 22-24, 2009. Follow-up information was required in five client records. The facility did not document follow-up within thirty days after discharge, as stated in the projects policy manual, in client records # 7 and 10.
Client record #7 discharge date 1/22/09, but follow-up not documented at time of inspection.
Client record #10 discharge date 2/11/09, but follow-up not documented at time of inspection.
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Plan of Correction
Program Supervisor will ensure that all clients being discharge will have follow-up documentation within thirty days after discharge. Program supervisor will monitor administrative staff monthly to ensure that client's has been notified following their discharge from sevices. Program supervisor will monitor this during weekly meetings with administative staff. Meeting (s) will be documented. During the meetings discherges and follow-up will be discussed to assure that follow-up procedure is being process. |