INITIAL COMMENTS
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This report is a result of an on-site licensure provisional renewal inspection and complaint investigation conducted on January 10, 2017 - January 11, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. West Chester 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:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records on January 10-11, 2017, the facility failed to hire a counselor who meets the qualification of a counselor per State standards in personnel record #5.
Employee #5 was hired on as a counselor on October 28, 2015 with a Bachelor Degree in Physical Education.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the November 5, 2016, May 19, 2015 and April 30, 2014.
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Plan of Correction
As of February 1, 2017, Employee #5 job duties has been reassigned to reflect those of a Counselor Assistant until he is able meet the requirements for a full Counselor position. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records on January 10-11, 2017. The facility failed to provide documentation of the required HIV/AIDS and TB/STD training in personnel records, #10.
Employee #10, an aide, was hired November 26, 2006. HIV/AIDS and TB/STD training was due to be completed no later than November 26, 2008.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #10 was transferred from the Eastern Regional Office to Gaudenzia House West Chester on November 14, 2016. Upon on arrival and review of her personnel records, the program scheduled Employee #10 for the training in question. As of this date, Employee #10 is no longer employed with the Agency and registration for the training in question were cancelled. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records on January 10-11, 2017, the facility failed to document the completion of 40 clock hours of training required for a counselor assistant in the first year of hire in personnel record #6.
Employee # 6 was hired on August 24, 2015. Employee # 6 only completed 30 clock hours of training since there hire date.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director will implement a training grid that will capture employees training hours to date. The Director will share the training grid with the Clinical Supervisor monthly, to gauge the current hours for each clinical employee. This should insure that each clinical employee has at least the minimum required hours for the year. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The physical plant inspection was conducted on January 10-11, 2017. The hot water temperature in the second floor restroom measured at 129 degrees F.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
On the date in question the hot water temperature was adjusted on the hot water heater to allow the water to get colder. Prior to the exit interview, program staff and auditor observed a decrease in the water temperature. The following day, Program staff re-assessed the water temperature and it did not exceed 120 degrees Fahrenheit. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on January 10-11, 2017, the facility failed to document a psychosocial evaluation in client records, #2, 4 and 6.
Client #2 was admitted on December 5, 2016.
Client #4 was admitted on November 21, 2016.
Client #6 was admitted on July 26, 2016.
The findings were reviewed with the facility staff during the licensing inspection.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the May 19, 2015 and November 5, 2015 inspections.
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Plan of Correction
Director has implemented a new system that require all clinicians to submit all of the clinical documentation on the daily basis which include but is not limited to psych social evaluations. Director generated a clinical documentation tracking form that captures the dates clinical documentation is due. The agency utilizes a CQI database that also identifies documentation deficiencies. Director reviews the CQI database monthly and any outstanding documentation must be submitted within 5 days. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records on January 10-11, 2017, the facility failed to document a comprehensive treatment plan in records 1, 4, 6, and 10. Additionally, the facility failed to either include support services, type/frequency of services or the client's signature in the following records, #3, 5, 7 and 9.
Client #1 was admitted on November 25, 2016. The comprehensive treatment plan was due no later than December 25, 2016.
Client #3 was admitted on November 24, 2016. The comprehensive treatment plan was completed on December 27, 2016, but failed to include support services.
Client #4 was admitted on November 21, 2016. The comprehensive treatment plan was due no later than December 21, 2016.
Client #5 was admitted on November 22, 2016. The comprehensive treatment plan was completed on December 23, 2016, but failed to include support services.
Client #6 was admitted on July 26, 2016. The comprehensive treatment plan was due no later than August 29, 2016.
Client #7 was admitted on September 5, 2016. The comprehensive treatment plan was completed on October 5, 2016, but failed to include support services.
Client #8 admitted on August 18, 2016. The comprehensive treatment plan was completed on September 23, 2016, but failed to include the type/frequency of services and the client's signature.
Client #10 admitted on June 28, 2016. The comprehensive treatment plan was due no later than July 28, 2016.
The findings were reviewed with the facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the May 19, 2015 and November 5, 2015 inspection.
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Plan of Correction
Director has implemented a new system that require all clinicians to submit all of the clinical documentation on the daily basis which include but is not limited to comprehensive treatment plans. Director generated a clinical documentation tracking form that captures the dates clinical documentation is due. The agency utilizes a CQI database that also identifies documentation deficiencies. Director reviews the CQI database monthly and any outstanding documentation must be submitted within 5 days. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
Based on the review of the client records on January 10-11, 2017, the facility failed to provide a complete client record in records, #2, 3, 4, 5, 8, 9 and 10.
Client # 2 was admitted December 5, 2016. The client was seen for individual and group sessions prior to the licensing inspection, the facility failed to document those services in the client ' s record of service.
Client # 3 was admitted November 24, 2016. The following progress notes were reviewed, but not documented on the client's record of service. Progress Notes: November 27, 2016, December 2, 4, 6, 7, 9, 26, 28, 2016 and January 3, 5, 6, and 9, 2017.
Client # 4 was admitted November 21, 2016. The client was seen for individual and group sessions prior to the licensing inspection, the facility failed to document those services in the client ' s record of service.
Client # 5 was admitted November 22, 2016. The following progress notes were reviewed, but not documented on the client's record of service. Individual sessions: December 19 and 30, 2016. Group sessions: December 14, 15 and 21, 2016.
Client # 8 was admitted August 18, 2016. The client was seen for individual and group sessions prior to the licensing inspection, the facility failed to document those services in the client ' s record of service.
Client # 9 was admitted September 28, 2016. The client was seen for individual and group sessions prior to the licensing inspection, the facility failed to document those services in the client ' s record of service.
Client # 10 was admitted June 28, 2016. The client was seen for individual and group sessions prior to the licensing inspection, the facility failed to document those services in the client ' s record of service for the August sessions.
The findings were reviewed with the facility staff during the licensing inspection.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the May 19, 2015 and November 5, 2015 inspection.
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Plan of Correction
Director has implemented a new system that require all clinicians to submit all of the clinical documentation on the daily basis which include but is not limited to client record of service. Director generated a clinical documentation tracking form that captures the dates clinical documentation is due. The agency utilizes a CQI database that also identifies documentation deficiencies. Director reviews the CQI database monthly and any outstanding documentation must be submitted within 5 days. |