INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. Winner Co-Occurring Women & Children Program 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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704.11(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 on a review of personnel records, the Project failed to ensure that each counselor completed at least 25 clock hours of annual training in two of five personnel records reviewed.
The findings include:
Five personnel records requiring documentation of 25 clock hours of annual training were reviewed from April 17, 2014 to April 18, 2014. The Project failed to provide documentation of 25 clock hours of annual training in the personnel records of employee # 4 from the Winner facility and employee # 4 from the Outreach II facility.
Employee # 4 from the Winner facility was hired as a counselor on March 29, 2010. Personnel record # 4 only included 15 clock hours of training for the 2013 training year.
Employee # 4 from the Outreach II facility was hired as a counselor on August 1, 2011. Personnel record # 4 only included 16 clock hours of training for the 2013 training year.
The findings were confirmed during an interview with the Training Institute Department Manager on April 18, 2014 at approximately 11:00 A.M.
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Plan of Correction
Clinical Supervisor will register and maintain training hours for clinical staff. Prevention Specialist Supervisor will insure training hours for Child Care staff and insure hours. Housemanager Supervisor will insure registration and maintain training hours for House managers. All other personnel will have training hours monitored by the Program Director. Hours will be reported out on in the monthly reports. Administrative Coordinator will collect trainings monthly and add to report for monitoring. |
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
Based on a review of personnel records, the Facility failed to instruct staff in the use of the fire extinguisher upon staff employment in two of two personnel records reviewed.
The findings include:
Two personnel records requiring documentation of fire extinguisher training were reviewed during the Administrative Review from April 17, 2014 to April 18, 2014.
Employee #2 was hired as a clinical supervisor on September 23, 2013. The personnel record did not include documentation of fire extinguisher training as of April 18, 2014.
Employee #3 was hired as a counselor on November 4, 2013. The personnel record did not include documentation of fire extinguisher training as of April 18, 2014.
The findings were confirmed during an interview with the Training Institute Department Manager on April 18, 2014 and the Facility Director on April 21, 2014.
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Plan of Correction
Director will insure trainings happen for all new employees during first day of employment at the facility. This will be documented and a training evaluation will be sent to the corporate office in 5 business days. This will be reported out on the monthly report maintained by the Administrative Coordinator and overseen by the Director monthly. |
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, the Facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in two of two personnel records reviewed.
The findings include:
Two personnel records requiring documentation that personnel had been trained to perform assigned tasks during emergencies were reviewed from April 17, 2014 to April 18, 2014. The Facility failed to ensure that the employee had completed emergency training prior to working their first shift.
Employee #2 was hired as a clinical supervisor on September 23, 2013. The personnel record did not include documentation of emergency training as of April 18, 2014.
Employee #3 was hired as a counselor on November 4, 2013. The personnel record did not include documentation of emergency training as of April 18, 2014.
The findings were confirmed during an interview with the Training Institute Department Manager on April 18, 2014 and the Facility Director on April 21, 2014.
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Plan of Correction
Program Director will insure that training is done on the first day of employment at the facility. Training will be documented and documentation will be submitted to the Training Institute within 5 business days. The Administrative Coordinator will list training on the monthly report and this will be overseen by the Director monthly. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of nine client records reviewed.
The findings include:
On April 21, 2014, nine client records requiring documentation of the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan were reviewed. The facility failed to document the type and/or frequency of treatment of rehabilitation services on the individual treatment and rehabilitation plan in client records # 1, 2, and 9.
Client # 1 was admitted January 9, 2014. The individual treatment and rehabilitation plan was completed February 14, 2014, but it did not include documentation of the type and frequency of treatment and rehabilitation services as of April 21, 2014.
Client # 2 was admitted February 7, 2014. The individual treatment and rehabilitation plan was completed April 11, 2014, but it did not include documentation of the type and frequency of treatment and rehabilitation services as of April 21, 2014.
Client # 9 was admitted September 11, 2013 and discharged November 8, 2013. The individual treatment and rehabilitation plan was completed October 16, 2013, but it did not include documentation of the type and frequency of treatment and rehabilitation services as of April 21, 2014.
The findings were confirmed during an interview with the facility director and clinical supervisor on April 21, 2014 at approximately 3:00 P.M.
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Plan of Correction
Program Director is overseeing treatment plans for the next 6 months to ensure compliance. Supervision has been done with the Clinical Supervisor and this is documented in her personnell chart. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual which included a record of services provided in two of ten client records reviewed, an individual treatment and rehabilitation plan in one of ten client records reviewed, and verification of work therapy in the comprehensive treatment plan in five of seven client records reviewed.
The findings include:
On April 21, 2014, ten client records requiring documentation of a complete client record were reviewed. The facility failed to document a record of services in client records # 2 and 4, an individual treatment and rehabilitation plan in client record # 4, and verification of work therapy in the comprehensive treatment plan in client records # 5, 7, 8, 9, and 10.
Client # 2 was admitted February 7, 2014. Client record # 2 contained documentation of progress notes for individual counseling sessions on 2/10/14, 3/28/14, 4/4/14, and 4/11/14 and documentation of progress notes for group counseling sessions on 2/12/14, 2/19/14, 3/4/14, 3/18/14, and 3/26/14. However, as of April 21, 2014, client record # 2 did not include documentation of a record of services for the specific services provided to the client.
Client # 4 was admitted March 13, 2014. Client record # 4 contained documentation of progress notes for individual counseling sessions conducted on: 3/24/14, 4/4/14, and 4/11/14. The record included documentation of progress notes for group counseling sessions conducted on: 3/18/14, and 4/1/14. Client record # 4 also included documentation of progress notes for family sessions conducted on: 3/18/14 and 3/24/14. However, as of April 21, 2014, client record # 4 did not include documentation of a record of services for the specific services provided to the client. In addition, the individual treatment and rehabilitation plan was due March 9, 2014. However, client record # 4 did not include documentation of an individual treatment and rehabilitation plan as of April 21, 2014.
Client # 5 was admitted on January 13, 2014 and the comprehensive treatment and rehabilitation plan was completed February 14, 2014. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 5, as of April 21, 2014.
Client # 7 was admitted January 6, 2014 and the comprehensive treatment and rehabilitation plan was completed February 15, 2014. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 7, as of April 21, 2014.
Client # 8 was admitted July 17, 2013 and discharged February 4, 2014. The comprehensive treatment and rehabilitation plan was completed August 20, 2013. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 8, as of April 21, 2014.
Client # 9 was admitted September 11, 2013 and discharged November 8, 2013. The comprehensive treatment and rehabilitation plan was completed October 16, 2013. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 9, as of April 21, 2014.
Client # 10 was admitted November 11, 2013 and discharged March 25, 2014. The comprehensive treatment and rehabilitation plan was completed December 5, 2013. The facility failed to document work therapy in the comprehensive treatment plan contained in record # 10, as of April 21, 2014.
The findings were confirmed during an interview with the facility director and clinical supervisor on April 21, 2014 at approximately 3:00 P.M.
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Plan of Correction
Program Director will over see treatment plans for the next 6 months to ensure compliance. Supervision has been done with the clinical supervisor and clinical staff and this supervision is documented in the personnel charts. |