INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gage House, LP 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 one of nine employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 7. Employee # 7 was hired as a counselor on March 3, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 7's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #7 job title changed to a "Counselor Assistant" effective 6/30/2022. The Director of Human Resources facilitated the signing of a new job description with this employee, which is on file with Human Resources.
This employee will continue working as a Counselor Assistant, providing treatment to individuals within the program. This employee will be scheduled for a minimum of one hour of direct observation on a weekly basis. She will also be scheduled a minimum of one hour of direct supervision on a weekly basis. This employee will attend trainings specific to the Drug & Alcohol field during her employment. The Clinical Supervisor / Program Manager (with certification) will provide the weekly scheduled observation and supervision hours. This will be documented by the identified individuals in the supervisory note and log. The employee is responsible for participation in the observation and supervision. The employee is also responsible for completing necessary trainings to expand D&A knowledge.
The Clinical Supervisor / Program Manager will monitor continued completion of requirements and training needs. The facility is in full compliance with this requirement as of 6/30/2022.
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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Cooking utensils were being stored in an open container in the kitchen. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Space planning occurred within the facility kitchen area to create storage / drawer space for cooking utensils. The Clinical Supervisor / Program Manager is responsible for achieving this change. On a day to day basis, all staff (Clinical Supervisor, Program Manager, Counselor, Counselor Assistant, Residential Aide, Rehabilitation Specialist, Certified Recovery Specialist, and Nurse) are responsible for maintaining compliance with this standard. As any of these staff roles are assigned to the kitchen area, they will ensure all utensils are cleaned / sanitized, and put away after use in the designated enclosed drawer space. The Clinical Supervisor/ Program Manager is responsible for overall compliance of this standard. The facility is in full compliance of this standard as of June 28, 2022. |
709.28 (c) 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.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 3.Client # 3 was admitted on March 29, 2022 and was still active at the time of the inspection. A letter allowing admit information dated May 27 and June 10, 2022 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There are times when a certification letter needs to be created for a client to facilitate other services in the community. The most common use of this letter is a form of certification for the client to acquire a birth certificate or photo ID. The Clinical Supervisor / Program Manager has reviewed the process of completing this type of letter, along with securing the appropriate consent to release the information with program staff during a staff meeting on 6/28/2022. This process will be maintained for all occurrences of these certification letters.
Clinical staff (Counselors), as well as the Clinical Supervisor / Program Manager, are responsible for maintaining compliance with this standard. The Clinical Supervisor, Program Manager, and Director of Risk Management will monitor completion and compliance with the standard. The agency is in full compliance with this standard as of June 30, 2022.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on four of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.Client # 4 was admitted on May 3, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 3, 2022 to a parent and emergency contact did not provide the specific information that was to be disclosed but instead stated "verbal form". Client # 5 was admitted on November 10, 2021 and discharged on January 31, 2022. An informed and voluntary consent from the client for the disclosure of information dated November 10, 2021 to a hospital did not provide the specific information that was to be disclosed but instead stated "other verbal communication". Also, an informed and voluntary consent from the client for the disclosure of information dated November 10, 2021 to a sponsor and December 14, 2021 to an emergency contact did not provide the specific information that was to be disclosed but instead stated "verbal form". Client # 6 was admitted on March 28, 2022 and discharged on April 10, 2022. An informed and voluntary consent from the client for the disclosure of information dated March 28, 2022 to a friend, son, and daughter did not provide the specific information that was to be disclosed but instead stated "verbal form". Client # 7 was admitted on May 25, 2022 and discharged on June 3, 2022. An informed and voluntary consent from the client for the disclosure of information dated May 25, 2022 to an aunt did not provide the specific information that was to be disclosed but instead stated "verbal form". These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Consent for Release of Information service entry in the electronic health record (EHR) has been updated to include a text field. Specific verbal information to be released will be documented in this text field. The form edit was completed in the EHR service entry form (D&A ROI Family/EC) on June 27, 2022 by the EHR System Specialist. This process was reviewed with all staff during the weekly staff meeting which was held on June 28, 2022. The Clinical Supervisor / Program Manager will review this process with staff again as needed to ensure understanding of the process. The Clinical Supervisor / Program Manager is responsible for oversight of the full process and compliance with the standard.
The Clinical Supervisor / Program Manager, and Director of Risk management will monitor completion of this process and monitor ongoing compliance with this standard. The facility is in full compliance with this standard as of June 30, 2022.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 7 days by letter.Client # 6 was admitted on March 28, 2022 and discharged on April 10, 2022. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program currently uses a checklist to facilitate completion of needed steps during the discharge process. Additional steps have been added to the checklist to indicate the requirement of an aftercare letter, and documentation (within the client record) of the letter being mailed to the client. The Clinical Supervisor / Program Manager is responsible for updating the checklist. The Clinical Supervisor / Program Manager has reviewed the updated checklist / discharge process during an individual supervision on 6/29/2022 with the Rehabilitation Specialist. The Rehabilitation Specialist is primarily responsible for the discharge process and documentation associated with the discharge. In addition, the internal aftercare process was reviewed with all program staff during a staff meeting held on June 28, 2022. The updated identified checklist will be utilized at the time of discharge to ensure compliance with mailing aftercare letters and completing documentation in the client record. The Clinical Supervisor / Program Manager is responsible for maintaining compliance with this standard by reviewing the completed discharge, including all required documentation. Once an individual discharge is complete, and reviewed by the Clinical Supervisor / Program Manager, the checklist for that discharge will be discarded.
The Rehabilitation Specialist, as well as the Clinical Supervisor / Program Manager, are responsible for maintaining compliance with this standard. The Clinical Supervisor, Program Manager, and Director of Risk Management will monitor completion and compliance with the standard. The agency is in full compliance with this standard as of June 30, 2022.
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