INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26 and 27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. - West Shore 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 25, 2009.
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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 a review of personnel records, the facility failed to document that all counselors met the qualifications for the position of counselor.
Findings:
Fourteen personnel records were reviewed on May 5 and 26, 2009. Documentation of qualifications for the position of counselor was required in five personnel records. The facility failed to document that one counselor met the qualifications for the position of counselor, the counselor represented by employee record #4.
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Plan of Correction
Verification of Counselor #4 degree in Sociology was FAXed to Department of Health, Drug and Alcohol Licensure on
the above date. The Program Supervisor will require a copy of degree and transcript at the time of the first interview to ascertain the compliance to the standard and this will be monitored by the Division Director at the time of the second interview. |
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 personnel records and an interview conducted with Human Resources Director, the facility failed to document that all non-clinical staff completed HIV/Aids training within the first two years of employment.
Findings:
Fourteen personnel records were reviewed on May 5 and 26, 2009. An interview was conducted with the Human Resources Director on June 1, 2009. The facility failed to document as of the ending date of this inspection that employee #12 completed HIV/Aids training within the first two years of employment. Employee #12 was hired on 6/18/06.
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Plan of Correction
Employee #12 will receive the mandatory HIV/BDAP approved training on line by September 1, 2009. This will be monitored by the Division Director for Outpatient Services and the Quality Assurance Director for compliance. This will ensure that the employee will receive the approved training. |
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 personnel and training records, the facility failed document at least 12 clock hours of training for the 2008 training year for one of two personnel.
Findings:
Personnel and training records for the project director and facility director were reviewed on May 5, 2009. The facility failed to document at least 12 clock hours of training for the 2008 training year for employee #2.
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Plan of Correction
Employee # 2 will receive 12 training hours annually as per policy from this time forward and it will be monitored by the Central Region Director. |
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 a review of personnel and training records, the facility failed to document that each counselor completed at least 25 clock hours of training for the 2008 training year in one of five counselor records reviewed.
Findings:
Fourteen personnel and training records were reviewed on May 5 and 26, 2009. Five counselors were required to complete at least 25 clock hours of training for the 2008 training year. The facility failed to document at least 25 clock hours of training for the 2008 training year for employee #4.
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Plan of Correction
Employee #4 will be held accoountable for completing the necessary 25 hours training from this date forward. The Program Supervisor will schedule training which was requested on the employee's individual training plan when the employee fails to register. This will be monitored by the Program Director. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of twelve client records reviewed.
Findings:
Twelve client records were reviewed on May 27 and 28, 20009. An informed and voluntary consent was required in seven client records. The facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records #1, 3, 4, 5, 6 and 7.
A consent in client record #1 to a Single County Authority (SCA), to secure funding, exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b) as it included "...treatment goals...".
A consent in client record #3 to a third party payer for funding, failed to address the specific information that would be released, stating only "funding information and requested information", which is not the specific information required. Another consent in client record #3, to a Single County Authority (SCA), did not specify the information to be released. Another consent in client record #3, to release information to a District Attorney, stated that information released would include "summary of initial evaluation and/or treatment progress reports and/or treatment discharge summary", which would exceed the limitations imposed at 4 Pa. Code Subsection 255.5(b).
In client record #4, a consent to release information to a county behavioral health organization failed to list the specific information that would be released and instead stated that the information released would include "funding information and requested information" which does not meet the requirement for specific information.
In client record #5 a consent to release information to an SCA did not list the specific information to be released.
In client record #6 a consent to release information form to a third party payer failed to list the specific information that would be released and stated only "funding information and requested information", which does not meet the requirement to list the specific information that would be released. Another consent to release information in client record #6 to an SCA did not include the specific information to be released.
In client record #7, a consent to release information to an SCA did not include the specific information that would be released.
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Plan of Correction
The Program supervisor will provide training regarding the completion of consent forms which meet the five areas for compliance to 4PA. Code subsection 255.5(b). The releases will be monitored for compliance for sixty days and thereafter for improvement through the Quality Assurance monthly client record review. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in seven of twelve client records.
Findings:
Twelve client records were reviewed on May 27 and 28, 2009. Counseling services provided according to the individual treatment and rehabilitation plan were required in eleven client records. The facility failed to document, either in the record of services or progress notes, that counseling services were provided according to the individual treatment and rehabilitation plan in client records #1, 3, 4, 9, 10, 11 and 12.
Individual sessions were prescribed one time per week in client record #1. The facility documented individual sessions on 2/13, 2/20, 3/6, 3/20, 4/3, 4/17, 5/1, 5/8 and 5/15/09.
Individual sessions were prescribed for one time per week in client record #3. The facility documented individual sessions on 1/2, 1/14, 1/20, 2/2, 2/9, 2/17, 2/26, 3/3, 3/12, 4/15, 4/30 and 5/13/09.
Individual sessions were prescribed for one time per week in client record #4. The facility documented individual sessions on 2/15, 2/20, 3/18, 3/25, 4/3, 4/15 and 4/30/09.
Individual sessions were prescribed one time per week in client record #9. The facility documented individual sessions on 12/11, 12/24, 1/2, 1/15, 1/27, 2/5, 2/13, 2/26, 3/6, 3/20, 4/2 and 4/9/09.
Individual sessions were prescribed one time per week in client record #10. The facility documented individual sessions on 9/4, 10/7, 11/15 and 11/22/08.
Individual sessions were prescribed one time per week in client record #11. The facility documented individual sessions on 10/21, 10/28, 11/4, 11/18 and 12/2/08.
Individual sessions were prescribed one time per week in client record #12. The facility documented individual sessions on 9/20, 10/3, 10/10, 10/17, 10/31, 11/7 and 12/13/08.
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Plan of Correction
The Program Supervisor will provide training for the counselors regarding the time and frequency documentation which is located on the treatment plan. This will be reviewed by the Program Supervisor at signature time for compliance of the treatment plan times with the Client Record of Service. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document a progress note after each significant client contact in six of eleven client records reviewed.
Findings:
Twelve client records were reviewed on May 27 and 28, 2009. A progress note after each significant client contact was required in eleven client records. The facility failed to document a progress note after each significant client contact in client records #1, 4, 5, 6, 10 and 12.
In client record #1, the record of service documented treatment sessions on 2/13, 3/29, 4/3, 4/24, 5/1 and 5/15/09 but no progress note was documented for these dates.
In client record #4, the record of service documented treatment sessions on 2/15, 2/18, 3/18, 3/20 and 4/15/09 but no progress note was documented for these dates.
In client record #5, the record of service documented treatment sessions on 2/8, 2/16, 2/18, 2/23, 2/26, 3/11, and 4/9/09 but no progress note was documented for these dates.
In client record #6, the record of service documented treatment sessions on 10/30, 12/2, 12/4, 12/11, 12/16, 12/23 and 12/26,08 but no progress note was documented for these dates.
In client record #10, the record of service documented treatment sessions on 10/14, 10/21, 10/28, 11/4, 11/12, 11/15, 11/18 and 12/9/08 but no progress note was documented for these dates.
In client record #12, the record of service documented treatment sessions on 10/17, 11/7 and 12/13/08 but no progress note was documented for these dates.
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Plan of Correction
Progress notes for individual counseling sessions will be documented within 72 hours of the service being delivered as per policy. Failure to complete the notes will result in disciplinary action by the Program Supervisor. The existing situation will be handled in two ways. The counselors will be requested to hand in to the Program Supervisor all progress notes for the charts noted and where there is none will be responsible for indicating in the client record that documentation was not completed in a timely way. All Counselors involved will receive the necessary disciplinary actions regarding the documentation of their client files. |