INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia at Sunbury 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level that documented it was developed annually with input from both the employee and the supervisor in two out of five personnel records reviewed. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed.
Employee #2 was hired as a facility director on May 16, 2016 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor.
Employee #3 was hired as a counselor on March 1, 2023 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor.
Employee #4 was hired as a counselor on April 18, 2022 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor.
Employee #5 was hired as a counselor on May 31, 2022 and was still in that position as of the date of the inspection. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Due to revisions made by the corporate training department as it relates to staff individualized training plans, supervisors neglected to obtain a separate staff signature verifying training goals were reviewed. Although new year training needs and goals are discussed in all performance reviews which receives staff signature a single training plan verification was not obtained. To correct this issue, all supervisors at Sunbury will review 2023 staff training needs and goals by June 15, 2023 and document this process in a supervisory session to be signed by the employee. Going forward this will be the same process in future years to ensure staff understand and participate in their own training goals. This will be part of the routine annual performance review requirement and will be reviewed for completion by facility Division Director. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan at the time of intake, as indicated in the facility ' s policy and procedure manual, in three out of seven records reviewed.
Client # 3 was admitted on January 24, 2023 and discharged on April 5, 2023. The preliminary treatment plan was not completed at intake; however, it was completed on January 31, 2023.
Client # 5 was admitted on March 7, 2023 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan in the client record.
Client # 7 was admitted on January 6, 2023 and still active at the time of inspection. The preliminary treatment plan was not completed at intake, however, was completed on January 18, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A clinical meeting will be held by June 15, 2023 to address clinical staff on treatment management procedures specific to the initial treatment plan process. All staff will be directed to complete a preliminary or initial treatment plan at the time of intake. Due to the enormous amount of requirements during that initial session, all intakes will be extended in time to ensure priority is given to completing the initial treatment plan. The Program Director will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |