INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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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704.11(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 11 staff records conducted during the on-site inspection and as part of the presubmission process, the facility failed to ensure that all of its staff received the required training in communicable diseases.
Staff Person #9 was hired as a counselor on 12/19/2016, and was required to complete 6 hour of training in HIV/AIDS, and 4 of training in TB/STDs by 12/19/2017, but at the time of the on-site inspection that staff person had no documented training in HIV/AIDS or documented training in TB/STDs.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Employee #9 will be registered by July 16, 2018 for the next available HIV/AIDS and TB/STDs trainings.
By July 30, 2018 the Program Supervisor will audit specific core trainings for all clinical staff that are needed within the first year of employment, including but not limited to HIV/AIDS, TB/STD. Audits will continue to be done on a quarterly basis as part of clinical supervision sessions. Scheduling of training will be the responsibility of the Program Supervisor. Training reports will now be completed monthly by the Program Supervisor. The Program Director will provide ongoing monitoring by signing off on the monthly training reports and through quarterly supervisory sessions withteh Program Supervisor. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of facility records conducted during the on-site inspection, the facility to ensure that it documented all of the required information during the intake process in 1 of 5 intake, evaluation and referral activity client records.
Client #9 was brought in for an intake, evaluation and referral assessment on 2/01/2018, but there was no documented signed consent to treatment form for the client.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
On 6/22/2018 during the clinical staff meeting all clinical staff were trained to complete a consent to treatment form at both the evaluation and the admission. The need for one during the evaluation was stressed.
The Program Supervisor will be trained on July 24, 2018. Program Supervisor has been on FMLA from June 12, 2018 through July 23, 2018.
The Program Supervisor will provide monthly chart audits to include completion of a signed consent to treatment during evaluation. This will be recorded on the monthly CQI report form. The Program Director will provide ongoing monitoring of the Program Supervisor for client chart compliance through review of the monthly CQI and through supervisory sessions with Program Supervisor |