INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29 and 30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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 27, 2008.
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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 upon a review of eight personnel records on May 12-16, 2008 & May 29 & 30, 2008, the facility failed to ensure that all staff met the educational and/or experiential requirements for the position that they were hired for.
One of four clinicians lacked the required experience based upon their degree. Employee #5 had a Bachelor of Science in Sociology; however, the employee only had three months of clinical experience rather than the required year.
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Plan of Correction
Counselor #3 will receive counselor assistant supervision and forty hours of training until they obtain the one year of clinical experience required. Documentation of direct supervision of counselor assistants will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. All new hires will have a through review of clinical experience to ensure they meet the regulations and will be hired for a position appropriate to that experience. The Project Director will monitor this review. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based upon a review of eight personnel records on May 12 through 16, 2008 and May 29 & 30, 2008, training feed back forms were applicable for six records reviewed. The facility failed to ensure that all staff completed feed back forms for all training attended.
Feed back forms for attended training were missing in employee records #3 & 7.
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Plan of Correction
Documentation of trainings will be monitored by Supervisors to ensure all trainings are scheduled, attended, and documented (Feedback Forms) within required time frames to ensure compliance with this regulation. Copies of Certificates and Feedback Forms will be archived in binders. |
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 upon a review of eight personnel records on May 12 through 16, 2008 and on May 29 & 30, 2008, it was determined that seven of the staff reviewed should have completed 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 . The facility failed to ensure that one of seven staff persons received the TB/STD training within the required timeframe.
Employee #7 was hired on 2/6/06 and the personnel record lacked any documentation to show that the employee completed the TB/STD required training as of the date of the visit.
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Plan of Correction
Employee # 7 is scheduled to complete 4 hours of TB/STD training on Tuesday, September 16, 2008. Individual Orientation Training Plans will be created and monitored by Supervisors to ensure mandatory trainings are scheduled, attended, and documented (Feedback Forms) within required time frames to ensure compliance with this regulation. Copies of Certificates and Feedback Forms will be archived in binders. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based upon a review of eight personnel records, one of two clinical supervisors failed to complete the mandatory 12 hours of annual training for the 2007 training year. Employee #3 lacked any documented training in the training file.
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Plan of Correction
Project was not in compliance with the standard due to employees Master Degree Program failing to meet licensing training requirements. Program Director has scheduled Employee #3 to attend the required number of documented trainings during the 2008 training year, as outlined in 704.11(e)(2). Project Director will develop and monitor Individual Annual Training Plans to ensure trainings to meet required training hours are scheduled, attended, and documented within required time frames to ensure compliance with this regulation. Copies of Certificates and Feedback Forms will be archived in binders. |
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 upon a review of eight personnel records on May 12 through 16, 2008 and May 29 & 30, 2008, two of the four counselor's records reviewed required documentation of training hours for the 2006 through 2007 training year.
The facility failed to maintain documentation of training completed in one of two records reviewed.
Personnel record #7 lacked any documentation of training hours completed for the training year.
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Plan of Correction
Individual Annual Training Plans will be created and monitored by Supervisors to ensure trainings are scheduled, attended, and documented to meet training hour requirements, within required time frames to ensure compliance. Copies of Certificates and Feedback Forms will be archived in binders. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based upon a physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. The lids were not able to be closed on the trash dumpsters and there was trash in bags piled up around the dumpsters.
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Plan of Correction
Project was not in compliance with the standard due to late trash pick-up. All trash, garbage and rubbish will be stored in containers with covers per our rubbish disposal contract. Building maintenance is responsible for rubbish removal. Supervisors will monitor rubbish storage and request additional trash pick-ups are booked to ensure this does not recur. |
709.28 (c)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based upon a review of six client records and an interview with a corporate representative, the facility failed to ensure that they obtained an informed and voluntary consent from the client for the disclosure of information contained in the client records in six of six client records reviewed.
Client records #1 through 6 contained a medical release form for the release of client identifying information for urine drug screens without identifying the laboratory that the facility intended to use. The consent stated that the information could be released to a laboratory of the facility's choosing. The facility did not have a Qualified Service Organization Agreement in place with any laboratories on file.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems. Director will request modification of existing medical release form to identify the specific laboratory utilized by Outreach Center I. And/or execution of a Qualified Service Organization Agreement. Forms will be reviewed by Continuous Quality Improvement Committee. |
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 upon a review of six client records, the facility failed to develop an individualized, comprehensive treatment plan in three of six records reviewed, specifically client records #1, 2 and 6. Treatment plans were not completed with the client within the third individual session as required by facility policy and procedure or had been completed prior to the completion of the biopsychosocial evaluation. The comprehensive treatment plan in record #1 was not completed until the 4th session. The comprehensive treatment plan in client record #2 was completed on 11/29/07 while the biopsychosocial evaluation had not been completed until 12/27/07. The comprehensive treatment plan in client record #6 was completed on 12/7/07 while the biopsychosocial evaluation had not been completed until 1/18/08.
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Plan of Correction
Project was not in compliance with the standard due to new untrained staff. An in-service facilitated by Division Managers, will be held Friday, July 11, 2006 to address Comprehensive Treatment Plan Development. Ongoing training will be provided by the Gaudenzia Training Institute. Comprehensive Treatment Plan Development will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document the medication and/or dosage in the client records. Six client records were reviewed at this facility. Three of those client records were required to document client medications. Two of those three client records did not contain documentation of the client's medication. Client record #5 listed the word "inhaler" as a medication. The name of the medication was not listed and there was no documentation of the dosage. Client record #6 was missing the dosage for two medications.
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Plan of Correction
Project was not in compliance with the standard due to agency form formatting problems and new untrained staff. An in-service facilitated by Division Managers, will be held Friday, July 18, 2006 to address Client Record: documentation of medication and/or dosage. Ongoing training will be provided by the Gaudenzia Training Institute. Client Record: documentation of medication and/or dosage will be reviewed by Supervisors during individual supervision sessions, and monitored through our Continuous Quality Improvement program. Forms will be reviewed by Continuous Quality Improvement Committee. |