INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 27, 2008 and May 28, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gudenzia Inc. Fountain Springs 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 June 27, 2008.
|
Plan of Correction
|
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.
|
Observations
The agency failed to provide twenty-five hours of training for the counselor. Based on a review of staff development records, personnel records, a review of the staffing requirements facility summary report and an interview with the facility director, only twelve hours of training was documented for the training year January 1, 2007 through December 31, 2007 for a counselor hired on July 26, 2004.
|
Plan of Correction
All counselors will receive twenty-five (25) hours of training yearly. Program Director will review training requirements for counselors in clinical meeting on 6/16/08 and will obtain written verification from counselors that the regulation was reviewed. Program Director will ensure trainings are scheduled and completed by staff in order to comply with the training regulation. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
|
Observations
The residential facility failed to install a handrail on stairways with two or more steps or with more than an 18 inch drop. Based on a physical plant inspection of the facility, six steps in the basement level of the facility that lead to the child care area did not have a handrail.
|
Plan of Correction
A handrail leading to the child care room will be installed. Program Director and Central Region Physical Plant Manager will oversee for completion of project. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
The agency failed to complete psychosocial evaluations within five days of admission. Agency intake and admission procedures require psychosocial evaluations be completed within five days of admission. Based on a review of eight client records, four of eight client records did not include an evaluation within five days of admission.
Client record # 1 Admitted January 9, 2008. Evaluation not completed until January 21, 2008.
Client record # 2 Admitted January 4, 2008. Evaluation not completed until January 12, 2008.
Client record # 3 Admitted January 31, 2008. Evaluation not completed until February 11, 2008.
Client record #6 Admitted December 26, 2007. No evaluation completed. Discharged on February 15, 2008.
|
Plan of Correction
All psychosocial evaluations will be completed within the time frame designated in the agency intake and admission procedures. Clinical Supervisor and Program Director will review procedures with all clinical staff in clinical meeting on 6/16/08 and will obtain written verification from counselors that the intake/admission procedures were reviewed. Clinical Supervisor will ensure continued compliance. |