INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Outpatient 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(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 personnel records on May 18, 2016, four of four counselors failed to complete 25 clock hours of training for the 2015 training year.
Employee # 4 was hired as a counselor on August 17, 2009 and completed 17.5 hours.
Employee #8 was hired as a counselor on January 14, 2014 and completed 13.5 hours.
Employee #9 was hired as a counselor on March 17, 2014 and completed 23.5 hours.
Employee #10 was hired as a counselor on August 26, 2013 and completed 13.5 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Required training hours will be reviewed with all counselors at Harrisburg Outpatient Program during the clinical meeting on 6/10/2016.
Ongoing, Clinical Supervisor will review Monthly Training reports with each counselor during scheduled supervision to ensure training requirements are being met.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records on May 18, 2016, the facility failed to show documentation that staff were trained upon employment as of the time of the licensing inspection.
Employee #5 was hired on October 26, 2015.
Employee #6 was hired on January 11, 2016.
Employee #7 was hired on August 17, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, New Hire Orientation Training Plan will include the goal of completing Fire Safety training within 7 days of employment provided by the immediate supervisor.
Additionally, a certificate of completion will be issued, documentation will be noted on the Monthly Training Reports and a copy of the certificate will be placed in the Employee File.
The Program Director will review these changes during the Management Meeting on June 10th, 2016. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records on May 18, 2016, the facility failed to show documentation that staff were trained as of the time of the licensing inspection.
Employee #5 was hired on October 26, 2015.
Employee #6 was hired on January 11, 2016.
Employee #7 was hired on August 17, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Orientation Training Plan will include the goal of completing Fire Extinguisher training within 7 days of employment provided by the immediate supervisor.
Additionally, a certificate of completion will be issued, documentation will be noted on the Monthly Training Reports and a copy of the certificate will be placed in the Employee File.
The Program Director will review these changes during the Management Meeting on June 10th, 2016. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of ten client records on May 18, 2016, two client records did not contain documentation of written acknowledgement of notification of their client rights.
Client #1 was admitted on October 26, 2015 and is still an active client.
Client #10 was admitted on February 8, 2016 and was administratively discharged on April 8, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Primary Counselor will complete documentation of notification of Client Rights with Client #1 during the next scheduled individual appointment. To be completed by June 30th, 2016.
Effective immediately, the monthly QI Chart Audit will include verification of written acknowledgement that each client has received notification of Client Rights.
QI chart audits will be conducted on a monthly basis and outcome reviews will be made with each clinician during scheduled weekly clinical meetings. Monthly audits are completed by Clinical Supervisor (s).
Clinical Supervisor will review admission/intake packets for completeness each month to ensure that all required forms are ready for completeness.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 ten client records on May 18, 2016, the facility failed to develop an individual and rehabilitation plan that was developed with client in client records, #9 and #10.
Client #9 was admitted to treatment on December 13, 2015. The plan was developed on January 7, 2016, but was not signed by the client until February 25, 2016.
Client #10 was admitted to treatment on February 8, 2016. The individual treatment and rehabilitation plan was missing from the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan for client #10 will be completed by identified counselor by 6/30/16.
The Clinical Supervisor will review policy and procedures for treatment plans with all staff during clinical staff meeting on 6/10/16.
Effective immediately, the Clinical Supervisor will insure that Treatment Plans are completed for each client on the day of their admission to treatment.
QI chart audits will be conducted on a monthly basis and outcomes reviewed with clinicians during clinical supervision as scheduled. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of ten client records on May 18, 2016, the facility failed to document treatment plan updates in three of six client records reviewed.
Client #1 was admitted on October 26, 2015 and was still an active client. Treatment plan updates for the following dates, January 20, 2016 and March 21, 2016 were not completed.
Client #3 was admitted on January 20, 2016 and was still an active client. Treatment plan update was due to be completed on on April 3, 2016 but was completed April 22, 2016.
Client #8 was admitted on October 13, 2015 and discharged on April 1, 2016. Treatment plan updates were due January 9, 2016 and March 8, 2016 were missing from the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan updates for client # 1 will be completed by designated counselor.
Clinical Supervisor will review policy and procedures of treatment plan updates with all staff during clinical staff meeting 6/10/16.
Clinical Supervisor will ensure that treatment plans are being completed in the appropriate time frames during monthly QI audits.
QI chart audits will be conducted on a monthly basis and outcomes reviewed with clinical staff during scheduled supervision. |