INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12 through 14 and 17 through 18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. -- Crossroads 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 December 17, 2008.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of employee records, the facility failed to ensure the one clinical supervisor out of one who needed the core curriculum training received it within six months.
The findings include:
Based on a November 13, 2008 review of the personnel and training records of one clinical supervisor who was hired for that position a year and a half ago, it was determined that he/she did not receive core curriculum training. Employee # 3 does not have two years supervisory experience in the provision of of clinical services and needs to obtain the training.
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Plan of Correction
Clinical Supervisors are scheduled to attend the training that is to be held January 12-16, 2009 - Program Director -will ensure that the supervisors attend the training. Clinical Supervisors are already confirmed for the training on January 12-16, 2009. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records the facility failed to document an informed consent to release information in fourteen of fourteen client records.
The findings include:
Fourteen client records were reviewed on November 18, 2008. The releases of information contained both "release to" and "receive from" sections. The "receive from" section of the consent to release information form contains language that detracts from an informed consent in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 13, 14, 15, 16 and 17.
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Plan of Correction
New releases of information are being implemented in all programs by the Progran Director - Both will meet with staff, train them and begin immediate implementation, Division Director will monitor - 12/18/2008 |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of five client records, the facility failed to document medical histories in two of five client records.
The findings include:
Five outpatient client records were reviewed on November 18, 2008. The facility did not document medical histories in client records # 15 and 17.
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Plan of Correction
Medical histories will be completed. Staff will be trained by supervisor and will be monitored. |
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 five client records, the facility failed to document medication records in two of five client records.
The findings include:
Five outpatient client records were reviewed on November 18, 2008. The facility did not document medication records in client records # 15 and 17.
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Plan of Correction
Client medications will be listed in all charts. Supervisor will monitor. |