INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia at Sunbury 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the personnel record and inquires to human resources staff and the facility director, the facility failed to document the required period of close supervision for a contracted counselor assistant.
The findings include:
Two personnel records were reviewed for the position of counselor assistant on May 7, 2013. One of the two personnel records reviewed was for a contracted counselor assistant. The counselor assistant represented in record # 4 was contracted on March 20, 2013. The staff member has a qualifying Bachelor's degree and therefore is required to have six months of documented close supervision. As of the date of inspection there was no documented verification that contracted counselor assistant represented in record # 4 had the required supervision for the first two months in the position.
The lack of documentation was confirmed by the Facility Director on May 21, 2013.
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Plan of Correction
Effective May 21, 2013, the Counselor Assistant represented in record # 4 will have weekly documented supervisory sessions conducted by an experienced Counselor III from the Middleburg office. Weekly supervisory sessions will be reviewed monthly by facility Director to ensure 6 months of direct supervision. Going forward, all Counselor Assistants whether contractual or salaried will be required to have the standard 6 months of documentation. |
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 client records and the facility's policies and procedures, the facility failed to document a treatment plan update in accordance with the facility's policies and procedures.
The findings include:
In reference to treatment plan updates the facility's policy states:
Treatment and rehabilitation plans will be reviewed and updated at least every sixty days. The treatment plan update will include an assessment of the client's progress in relationship to stated goals.
Eight client records requiring treatment plan updates were reviewed on May 21, 2013. The treatment plan updates were deficient in three out of eight client records, specifically records #1, 3, and 4.
Client #1 was admitted on December 19, 2012. The treatment plan update which occurred on May 17, 2013 did not document the progress on goals for client #1.
Client #3 was admitted on October 2, 2012. A treatment plan update had occurred on December 12, 2012 and another was due by February 12, 2013. The treatment plan update was not documented until March 6, 2013.
Client #4 was admitted on February 11, 2013. The treatment plan update which occurred on March 28, 2013 did not document the progress on goals for client #4.
The findings were discussed with the facility director during the exit interview.
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Plan of Correction
An all staff in service training will be held on July 19, 2013 to address clinical staff on treatment management procedures specific to the treatment planning process. All staff will be directed to update treatment plans every 60 days or sooner. Staff will be directed to document progress on previous goals. The Clinical Supervisor will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based upon a review of the client records and the facility's policies and procedures, the facility failed to document case consultations as per their policy.
The findings include:
In reference to the timeframes for the completion of case consultations, the facility's policy states:
Case Consults are performed every 90 days for outpatient.
Eight client records requiring documentation of case consultations were reviewed on May 21, 2013. Three out of eight client records did not have documentation of a case consultation, specifically clients #4, 6, and 7.
Client #4 was admitted to treatment on February 11, 2013. A case consultation had not been documented until May 20, 2013.
Client #6 was admitted to treatment on August 2, 2012 and discharged on February 27, 2013. A case consultation was documented late on November 13, 2012; another case consultation was due by February 13, 2013 for client #6 but had not been documented until May 6, 2013.
Client #7 was admitted to treatment on November 30, 2012 and discharged on March 5, 2013. A case consultation was due by February 28, 2013 for client #4 but had not been documented until March 5, 2013.
The findings were confirmed by the clinical supervisor during the exit interview.
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Plan of Correction
An all staff in service training will be held on July 19, 2013 to address clinical staff on treatment management procedures specific to case consults. All staff will be directed to update case consults every 90 days or sooner. The Clinical Supervisor will review case consults for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. The Program Director will review compliance through the QI and UR reports on a monthly basis. |