INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 20-21, 2010 licensure renewal inspection. The follow-up inspection was conducted on August 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gateway Erie 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 September 20, 2010.
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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 the review a personnel records and an interview with the facility director during a plan of correction follow up inspection, the facility failed to ensure that each counselor met the qualifications for the position in one of one personnel record.
Findings:
One personnel record was reviewed on August 23, 2010 for compliance with the qualifications for the position of a counselor. The facility did not provide documentation, in personnel record # 1, that the counselor met at least one of the qualifications for the position of a counselor.
Personnel record # 1, was originally reviewed as a counselor at the licensing inspection on January 20-21, 2010. This counselor did not meet the qualifications for the position of counselor based on a Bachelor of Science degree in Administration of Justice. In addition, the bachelor's degree course transcript was reviewed by the Division on January 5, 2010 and was found not to meet the educational component for the position of counselor. The plan of correction was to re-assign this counselor as a counselor assistant. The facility director was interviewed on August 23, 2010 and confirmed the counselor reviewed had not been reassigned as a counselor assistant and had remained listed as a counselor.
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Plan of Correction
We will maintain the individual as a Counselor Assistant with a waiver granted by the Division of Drug and Alcohol Program Licensure on September 13,2010 for the requirement for close supervision and direct observation. This is based upon her years of experience and the fact that she once held a CAC in the State of Pennsylvania.
The staff member along with the Division of drug and Alcohol Program licensure has sought clarification of the degree equivalency between Administration of Justice and Criminal Justice Degrees. This rendering is forthcoming.
In the meantime the staff member has continued to persure the reaquisition of the CAC by meeting the training requirements.
The decision to grant her full Counselor status or continue as a Counselor Assistant will be made by October 31,2010. The implementation will be overseen by the Program director in conjunction with the Division of Drug and Alcohol Program Licensure. |
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 the review of client records, the facility failed to document follow up contact in three of three inpatient client records.
The findings include:
Fourteen client records were reviewed on August 23, 2010. Eight client records were reviewed as inpatient client records. Three inpatient client records were reviewed as closed records and required follow up contact. Per the agency's policy, follow up contact is required within one month of discharge. The facility did not document follow up in client records # 9, 10 and 11.
Client # 9 was discharged on May 19, 2010. Follow up was due by June 19, 2010. There was no documentation of follow up contact in the client's record as of August 23, 2010.
Client # 10 was discharged on June 26, 2010. Follow up was due by July 26, 2010. There was no documentation of follow up contact in the client's record as of August 23, 2010.
Client #11 was discharged on July 6, 2010. Follow up was due by August 6, 2010. There was no documentation of follow up contact in the client's record as of August 23, 2010.
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Plan of Correction
Gateway Rehabilitation Center Therapy Department under the direction of the Vice President of therapy Programs has instituted a process of follow up with former patients at the prescribed intervals.
This process was estabished the week of September 6,2010.Clerical staff at Gateway Erie give notification the clerical staff at the headquarters to begin follow up.Data is analyzed by the Vice President of Therapy Programs and disseminated to Program Directors and Division Managers
The program Director will check this process quarterly to insure that the process continues as planned. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on the review of client records and an interview with the resource manager, the facility failed to document follow up contact in three of three outpatient client records.
The findings include:
Fourteen client records were reviewed on August 23, 2010. Six client records were reviewed as outpatient client records. Three outpatient client records were reviewed as closed records and required follow up contact. Per the agency's policy, follow up contact is required within one month of discharge. The facility did not document follow up in client records # 12, 13 and 14.
Client #12 was discharged on June 17, 2010. Follow up was due by July 17, 2010. There was no documentation of follow up contact in the client's record as of August 23, 2010.
Client # 13 was discharged on May 13, 2010. Follow up was due by June 13, 2010. There was no documentation of follow up contact in the client's record as of August 23, 2010.
Client # 14 was discharged on April 8, 2010. Follow up was due by May 8, 2010. There was no documentation of follow up contact in the client's record as of August 23, 2010.
A telephone interview with the resource manager on August 30, 2010 confirmed that there was no follow up documentation in the aforementioned client records.
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Plan of Correction
The Out Patient Counselor was instructed by the Program Director to fill out the follow up data sheet for each patient being discharged.This occured on 9/21/2010. This will trigger the follow up process.
Gateway Rehabilitation Center Therapy Department under the direction of the Vice President of therapy Programs has instituted a process of follow up with former patients at the prescribed intervals. This process was estabished the week of September 6,2010.
Clerical staff at Gateway Erie give notification the clerical staff at the headquarters to begin follow up.Data is analyzed by the Vice President of Therapy Programs and disseminated to Program Directors and Division Managers.
The program Director will check this process quarterly to insure that the process continues as planned.
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