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 22, 2009 licensure renewal inspection. The follow-up inspection was conducted on November 4, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 December 3, 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 in 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
This could not be re-evaluated until the next licensing inspection. Please resubmit the original plan of correction.
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Plan of Correction
Director and/or Supervisor(s) will create Individual Training Plans annually for each employee by January 31, 2010 to meet the regulations. Division Diretor and/or Director will make ensure that the documentations are presented 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.
This cannot be re-evaluated until the next licensing inspection. Please resubmit your original plan of correction.
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Plan of Correction
Employee number 7 is schedule to complete the required 25 clock hours of training annually for year of 2009. Documentation of trainings will be monitored by Director and Clinical supervisor to ensure all trainings are scheduled, attended, and documented (feedback forms) within the required time frames to ensure compliance with this regulation. Copies of certificates will be archived in binders. |
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 client records, the facility failed to document counseling services provided according to the individual treatment plan in seven of seven client records.
Findings:
Seven active client records were reviewed on November 4, 2009 for counseling services provided in accordance with the treatment plan. The facility did not document counseling according to the treatment plan in client record # 1, 2, 3, 4, 5, 6 and 7.
Client record # 1, the treatment plan states group counseling sessions would be provided twice a week and individual sessions one time a week. During the follow-up inspection the facility failed to provide services in accordance with the treatment plan.
The week of 8/9/2009 through 8/15/2009. The client only attended one group session on 8/10/2009. The facility failed to provide one group session and one individual counseling session this week.
The week of 8/16/2009 through 8/22/2009 the facility did not provide any services to the client according to the group notes and record of service.
The week of 8/23/2009 through 8/29/2009 the facility failed to provide individual counseling this week.
The week of 8/31/2009 -9/5/2009 the facility failed to provide individual counseling this week.
The week of 9/6/2009 through 9/12/2009 the facility failed to provide individual counseling this week.
The week of 9/13/2009 through 9/19/2009 the facility failed to provide any services. The facility did document that the client was a no show for group on 9/14/2009.
The week of 9/20/2009 to 9/26/2009 the client attended group and individual on 9/21/2009. However, the facility failed to provide a second group session this week.
Client record # 2, the treatment plan states individual counseling sessions would be provided one time a week and that there would be two groups per week.
The week of 8/5/2009 through 8/8/2009 the facility failed to provide an individual session this week.
The week of 8/9/2009 through 8/15/2009 the facility failed to provide group sessions this week.
The week of 8/16/2009 through 8/22/2009. The facility failed to provide group session for this week.
The week of 8/23/2009 through 8/29/2009 the facility failed to provide any services. The record of service did not indicate that the client was a no show.
The week of 9/6/2009 through 9/12/2009 the facility failed to provide any services. The record of service did not indicate that the client was a no show.
The week of 9/13/2009-9/19/2009 the facility failed to provide any services. The record of service did not indicate that the client was a no show.
The week of 9/20/2009 through 9/26/2009 the facility failed to provide group sessions this week.
The week of 9/27/2009 through 10/3/2009 the facility failed to provide any services. The record of service did not indicate that the client was a no show.
The week of 10/4/2009 through 10/10/2009 the facility failed to provide any services. The record of service did not indicate that the client was a no show.
The week of 10/11/2009 through 10/17/2009 the facility failed to provide any services. The record of service did not indicate that the client was a no show.
The week of 10/18/2009 through 10/23/2009 the facility failed to provide group sessions this week.
Client record # 3, the treatment plan states that individual counseling sessions would be provided one time a week and that there would be two groups per week.
The week of 8/16/2009 through 8/22/2009 the facility failed to provide group sessions this week.
The week of 8/23/2009 through 8/29/2009 the facility failed to provide individual counseling this week.
The week of 8/30/2009 through 9/5/2009 the client attended group on 9/3/2009. The facility failed to provide one group session and one individual counseling session this week.
The week 9/6/2009 through 9/12/2009 the client attended one group on 9/10/2009. The facility failed to provide one group session this week.
The week of 9/13/2009 through 9/19/2009 the client attended group on 9/15/2009. The facility failed to provide one group session this week.
The week of 9/20/2009 through 9/26/2009 The client attended group on 9/24/2009. The facility failed to provide one group session and one individual counseling session this week
The week of 9/27/2009 through 10/3/2009 the client attended one group on 10/1/2009. The facility failed to provide one group session this week.
The week of 10/4/2009 through 10/10/2009 the client attended group on 10/8/2009. The facility failed to provide one group session and one individual counseling session this week.
The record of service stops after the group on 10/8/2009. The record of service did not indicate if the client didn't show up for an appointment.
Client record # 4, the treatment plan states individual counseling sessions would be provided one time a week and that there would be two groups per week.
The week of 8/9/2009 through 8/15/2009 the client attended a group session on 8/14/2009. The facility failed to provide one group session and one individual counseling session this week.
The week of 8/23/2009 through 8/29/2009 the facility failed to provide two groups this week.
The week of 8/30/2009 through 9/5/2009 the facility failed to provide two groups this week.
The record of service ends on 9/2/2009. The record of service did not indicate if the client didn't show up for an appointment.
Client record # 5, the treatment plan states individual counseling sessions would be provided one time a week and that there would be two groups per week.
The week of 9/13/2009 through 9/19/2009 the facility failed to provide two groups this week.
The week of 9/20/2009 through 9/26/2009 the facility failed to provide two groups this week.
The week of 9/27/2009 through 10/3/2009 the facility failed to provide two groups this week.
The week of 10/4/2009 through 10/10/2009 the facility failed to provide any services. The record of service did not indicate that the client was a no show.
The week of 10/11/2009 through 10/17/2009 the facility failed to provide two groups this week.
The week of 10/18/2009 through 10/24/2009 the facility failed to provide any services. The record of service did not indicate that the client was a no show.
The week of 10/25/2009 through 10/28/2009 the facility failed to provide two groups this week.
Client record # 6, the treatment plan states individual counseling sessions would be provided one time a week and that there would be three groups per week.
The week of 8/23/2009 through 8/29/2009 failed to provide two groups this week.
The week of 8/30/2009 through 9/5/2009 the facility failed to provide one group and one individual session this week.
The week of 9/13/2009 through 9/19/2009 the facility failed to provide two group sessions.
The week of 9/27/2009 through 10/13/2009 the facility failed to provide three group sessions and one individual session this week.
The week of 10/4/2009 through 10/10/2009 the facility failed to provide three group sessions and one individual session this week.
The week of 10/11/2009 through 10/17/2009 the facility failed to provide two groups and one individual session this week.
Client record # 7, the treatment plan states individual counseling sessions would be provided one time a week and that there would be two groups per week.
The week of 8/16/2009 through 8/22/2009 the facility failed to provide one group session this week.
The week of 8/23/2009 through 8/29/2009 the facility failed to provide one group and one individual session this week.
The week of 8/30/2009 through 9/5/2009 the facility failed to provide one group this week.
The week of 9/6/2009 through 9/12/2009 the facility failed to provide one group this week.
The week of 9/13/2009 through 9/19/2009 the facility failed to provide two groups and one individual session this week.
The week of 9/20/2009 through 9/26/2009 the facility failed to provide two groups this week.
The week of 9/27/2009 through 10/3/2009 the facility failed to provide two groups this week.
The week of 10/4/2009 through 10/10/2009 the facility failed to provide two groups and one individual session this week.
The week of 10/11/2009 through 10/17/2009 the facility failed to provide two groups and one individual session this week.
The week of 10/18/2009 through 10/24/2009 the facility failed to provide one group and one individual session this week.
The week of 10/25/2009 through 10/31/2009 the facility failed to provide one group and one individual session this week.
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Plan of Correction
An in-services was held on October 30, 2009 by clinical staff and Division Director to address Comprehensive Treatment Plan(s). Going forward clinical supervisor and/or Director will monitor clinical charts daily to ensure that the clinical staff is utilizing information provided in recent traing for treatment plans.Counselor will document all missed schedule sessions (individual or group to ensure that frequencies are measure as treatment is prescribed. |