INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 2008 through May 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Common Ground 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 24, 2008.
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Plan of Correction
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709.64(c)(5) LICENSURE Educational support services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
Based on a review of referral agreements and staff interview the facility failed to provide documentation of a letter of agreement or any other evidence that the project was able to assist the client in obtaining educational services.
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Plan of Correction
The Program Director has contacted Tri-County OIC, Inc. and HACC to renew the facility's referral agreements for educational services to clients. A new written agreement has been sent for signature. The Program Director will review letters of agreement on an ongoing quarterly basis to assure renewal in a timely manner and manintain compliance. |
709.51(e)(5) LICENSURE Educational support
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(5) Educational.
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Observations
Based on a review of referral agreements and staff interview the facility failed to provide documentation of a letter of agreement or any other evidence that the project was able to assist the client in obtaining educational services.
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Plan of Correction
The Program Director has contacted Tri-County OIC, Inc. and HACC to renew the facility's referral agreements for educational services to clients. A new written agreement was sent for signature by 6/30/08. The Program Director will review letters of agreement on an ongoing quarterly basis to assure renewal in a timely manner and manintain compliance. |
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 and staff interview, the facility failed to ensure that all staff received the required minimum hours of HIV/AIDS and TB/STD training within the required time frame. HIV/AIDS training and TB/STD training was missing in one out of six personnel records reviewed, #5.
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Plan of Correction
The Program Director reminded the other supervisory staff of the importance of obtaining approved HIVAIDS and TB/STD training for all staff. The Program Supervisor scheduled Employee # 5 to attend the next available training, currently set for 8/26/08. All supervisory staff and the Director will review employee training records quarterly to monitor progress, prevent future deficiency, and maintain compliance with training requirements. |
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 and staff interview, the facility failed to ensure that all staff received the required number of annual training hours in one out of six personnel records reviewed, #5. Employee #5 was required to have 40 hours of annual training. Employee #5 only had 26 hours of annual training documented.
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Plan of Correction
The Program Supervisor will continue to register and schedule at least 4o hours of annual training for Counselor Assistants. The Program Director will assure that copies of training documentation and certificates will be forwarded to the corporate training institute for inclusion in the employee's training record maintained at the corporate office. At least 40 hours training will occur by the end of the current training year on 12/31/08. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of the facility's staff schedule and staff interview, the facility failed to maintain the required staff to client ratio. On April 28, 2008, the staff to client ratio was one to nine.
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Plan of Correction
The Nurse Manager will assure that the staff to client ratio does not exceed one to seven in detox. Should census rise above seven, the Program Director will authorize overtime as needed at request of the Nurse Manager who will coordinate additional staff coverage. Issue resolved 6/10/08. Ongoing conformance will be reviewed monthly by the Nurse Manager and Program Director. |