INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Gaudenzia Inc. Harrisburg Concept 90 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 May 14, 2020, the facility failed to document that each counselor met both the education and experiential qualifications for the position.
Employee #4, whom was hired as a counselor on March 30, 2020, did not meet the one-year experience requirements to be a counselor with a bachelor's degree.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director and Division Director have taken a look at the job description for Employee #4 who is listed on the roster as intake counselor. The title for this position will be updated to reflect intake specialist as this individual does not hold a case load. The program director will continue to work with leadership in the future to ensure all individuals hired in the counselor role meet the qualifications. Program Director will ensure that Employee #4 continues to receive all supervision and training as was planned for this individual. The individual is in an education program to pursue a master's degree as well, which is anticipated to be completed in a year. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to ensure that all staff were instructed in the use of the fire extinguishers upon staff employment.
Employee #9 was hired as a counselor assistant on September 19, 2019 and was still in this position at the time of inspection. The employee did not receive training until October 2, 2019.
These findings were discussed with facility during the licensing inspection.
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Plan of Correction
Employee #9 did receive training on use of the fire extinguisher via verbal training during the first week of hire following hire date of 9/19 as part of the orientation to the program for new hires. The sign off on the training that was to be completed within 7 days of hire was returned late on 10/2. Program Director has a process in place in which new hires receive verbal overview of the training and a piece in which they must read and sign off. This is due back within 7 days of hire. Program Director and Clinical Supervisor will assure this is being completed in the time frames established and all sign off sheets are being returned timely manner. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 14, 2020 the facility failed to ensure that all employees were trained to perform assigned tasks during emergencies upon hire.
Employee #9 was hired as a counselor assistant on September 19, 2019 and was still in this position at the time of inspection. The employee did not receive training until October 2, 2019.
These findings were discussed with facility during the licensing inspection.
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Plan of Correction
Employee #9 did receive training on emergency safety via verbal training during the first week of hire following hire date of 9/19 as part of the orientation to the program for new hires. The sign off on the training that was to be completed within 7 days of hire was returned late on 10/2. Program Director has a process in place in which new hires receive verbal overview of the training and a piece in which they must read and sign off. This is due back within 7 days of hire. Program Director and Clinical Supervisor will assure this is being completed in the time frames established and all sign off sheets are being returned timely manner. |