INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27, 2008 through May 28, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Harrisburg Outpatient 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 June 26, 2008.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and staff interview, the facility failed to notify the client, in writing, of a decision to terminate the client's treatment in one of two records reviewed, #10. A termination letter was never sent to client #10.
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Plan of Correction
Program Supervisor will train all clinical personnel regarding involuntary termination. All discharged charts reviewed by the administrative coordinator for utilization review will include this letter to the client.
Training will occur on Friday, June 26, 2008 in clinical meeting. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records and staff interview, the facility failed to give the client an opportunity to request reconsideration of a decision terminating treatment in one of two records reviewed, #10. A termination letter was never sent to client #10.
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Plan of Correction
Program Supervisor is responsible for training all clinical personnel regarding involuntary termination. The Administrative Coordinator will review discharges for utilization review for this aspect of non-compliant client discharge.
Training will occur on Friday, June 26, 2008 in clinical meeting. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the hot water did not exceed 120 degrees Fahrenheit. The water temperature registered at 140 degrees Fahrenheit.
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Plan of Correction
The hot and cold water was corrected immediately by the central region facilities manager. During facility walk throughs by the Central Region Facilities Manager, the water will be tested for compliance with the standard. The Program Director will monitor the walk through. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and staff interview, the facility failed to instruct staff in the use of the fire extinguisher within the required time frame for two of two new employees reviewed, #5 and 8. Fire extinguisher training for employee #5 was conducted one month late. Fire extinguisher training for employee #8 conducted two months late.
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Plan of Correction
The Program Supervisor will be held responsible for completing the fire extinguisher training for new hires in a timely fashion. Form will be signed off at appropriate date. The paperwork for this training will be given to the Administrative Coordinator for review at the end of the 1st week of hire to check for compliance to this standard. Fire extinguisher training will be reported in administrative meetings for new hires. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a complete personal history in thirteen of thirteen records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13. A personal history was missing in one of thirteen client records reviewed, #6. The family history included one word answers and/or minimal data regarding the family of origin in three of thirteen client records reviewed, #5, 8 and 13. The family history was missing in two of thirteen client records reviewed, #2 and 4. The legal history included conflicting information in two of thirteen client records reviewed, #4 and 5. The employment history was missing in thirteen of thirteen client records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13. The form only asks the client about employment within the last two years rather than within the client's lifetime.
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Plan of Correction
The Program Supervisor will train staff for the psychosocial form and need for elaboration in all sections due to form format with intake workers and clinical staff. The training for this will occur on Friday, June 26, 2008, in the clinical meeting. The psychosocial will be reviewed by the Program Supervisor in the QI process to be sure of training implementation. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of training records and staff interview, the facility failed to ensure all staff persons received at least four hours of TB/STD training within the required time frame in one of eight records reviewed, #6.
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Plan of Correction
Training will be monitored on a monthly basis for compliance with policy by the clinical supervisor and administrative coordinator so that the necessary training is in compliance. Training for #4 will be scheduled and completed. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of training records and staff interview, the facility failed to ensure that the facility director completed at least twelve hours of annual training. The facility director had zero training hours for the 2007 annual training year.
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Plan of Correction
The facility director will receive 12 hours of training annually. The training hours will be submitted to the Central Region office of Gaudenzia for review and submission to the Gaudenzia Corporate office. This will be monitored by the Central Region Office. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of training records and staff interview, the facility failed to ensure that each counselor assistant completed at least thirty hours of annual training in one of eight records reviewed, #6. Staff #6 had 27.5 training hours for the 2007 annual training year.
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Plan of Correction
The Program Supervisor is responsible for monitoring for counselor assistant which meets requirements. The training hours will be submitted to the Central Region Office for review and submission to the Gaudenzia Corporate Office. This will be monitored by the Central Region Office. |