INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on April 3, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, Gaudenzia Inc 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 review of personnel records, the facility failed to provide documentation of the required twenty-five clock hours of annual training in two of the five records reviewed. Employee # 4 was hired as a counselor on August 25, 2008 and was still in this position at the time of the inspection. After review of the personnel records, there were only 12.5 training hours documented. Employee # 5 was hired as a counselor on June 25, 2018 and was still in this position at the time of the inspection. After review of the personnel records, there were only 20 training hours documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 03/22/2020 Employee #4 is no longer employed with the organization.
Effective immediately staff and supervisor will schedule all staff members as part of their staff development with the required 25 hrs. of annual training. Employee #5 had 20 hrs of training at the time of this audit. There was a lack of follow-up with the remaining 5 hours when training cancellations occurred. Therefore, when notice of cancellation occurs an alternate training will be scheduled within 24 hrs of notice being received. The on-site supervisor will maintain a monthly training grid indicating training attended and hours of training received. The grid will be sent to the Division Director as well as Eastern Region Office on a quarterly basis to ensure all staff meet the required training hours annually.
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704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on review of The Staffing Requirements Facility Summary Report on March 26, 2020. Employee # 3 was hired as a clinical supervisor on July 22, 2019 and was still acting in that position. Employee #3 was reported to have 7 hours per week devoted to their 7 clients on their caseload.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.The FTE counselor ' s caseload calculation is as follows: 7/40 = .175(FTE); 7/.175 = 40, which equals to a client/counselor ratio of 40:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 ratios have now been adjusted to reflect the corrected hours dedicated to the client services. Staff to client ratios now meet the outlined DDAP regulations. Supervisor has a caseload of 7 clients and devotes 9 hrs per week to clinical work.
9 hrs/40 hrs= 0.255
7/0.225= 31:1 ratio
31:1 Falls within the 35:1 ratio based on licensing regulations.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on review of the facility fire drill log received on March 26, 2020, the facility failed to provide documentation of fire drills being conducted the months of March, April, May, and June 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately: monthly fire drills will be conducted on both shifts to ensure compliance with standard. Also, CQI manager will ensure compliance as part of quarterly CQI audits and Program Supervisor will ensure there is monthly compliance to this standard. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on review of the facility fire drill log received on March 26, 2020, the facility failed to provide documentation of any problems encountered during the fire drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately the Program Supervisor shall ensure that all fire drills are documented on the agency evacuation report. By completing this report and addressing the question on the form "Providing recommendations to improve efficiency/effectiveness in the future", the area to address any problems encountered during the fire drill will be addressed. The Division Director shall verify documentation on a quarterly basis. |