INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 7, 2024, 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of four personnel records, the facility failed to ensure that one counselor assistant was given a written semiannual performance evaluation based upon measurable performance standards.
Employee # 4 was hired on June 4, 2023 as a counselor assistant and is still in that position at the time of the inspection. There was no documentation that Employee #4 received a semiannual performance evaluation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
No later than 11/8/24 a six month review will be completed to see if Counselor Assistant has met the satisfactory rating. The DDAP requirements of Counselor Assistant will be reviewed with the Division Director prior to hiring any Counselor Assistant's should we look to hire someone in that position. Should a Counselor Assistant be hired moving forward the Division Director will ensure the documentation is being properly completed on the staff member. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of four personnel records, the facility failed to ensure that one counselor assistant was counseling clients under the supervision of a trained counselor or clinical supervisor based on their education. Employee #4 was hired on June 4, 2023 as a counselor assistant. Employee #4 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. There was no documentation that Employee #4 received direct observation from June 4, 2023 to April 30, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning on 5/9/24, Counselor Assistant will undergo direct supervision for a period of at least three months that is completed by Outpatient Director. At the completion of 3 months Division Director and Outpatient Director will review how Counselor Assistant has been progressing and we will look to move her to close supervision if it is positive review. If not direct supervision will continue to occur. During the 3 month time of direct supervision a case review will be completed with Counselor Assistant on one of her cases. No later than 11/8/24 a six month review will be completed to see if Counselor Assistant has met the satisfactory rating. Should a Counselor Assistant be hired in the future the Outpatient Director will review with the Division Director the documentation requirements of a Counselor Assistant. The Division Director will be responsible for ensuring that this is being done correctly with the Clinical Supervisor. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation per the facility ' s policy and procedure manual in three out of seven records. The facility ' s policy states a psychosocial evaluation is completed within thirty days of admission.
Client #2 was admitted on January 2, 2024 and was still active at the time of the inspection. The psychosocial evaluation was due no later than February 2, 2024; however, there was no documentation of a psychosocial evaluation.
Client #5 was admitted on August 8, 2023 and was discharged on February 2, 2024. The psychosocial evaluation was due no later than September 8, 2023; however, there was no documentation of a psychosocial evaluation.
Client #6 was admitted on August 21, 2023 and was discharged on January 9, 2024. A psychosocial evaluation was due no later than September 21, 2023; however, it was not completed until November 2, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During clinical meeting on June 12th, 2024, the Division Director will review the workflow with the counselors that will include review of completing the psychosocial being completed within 30 days of admission. The counselors will be required to document the workflow and submit it to the Clinical Supervisor weekly for verification of the completion of the required documentation including the psychosocial histories or the next 60 days. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultations within the regulatory timeframe established by the facility ' s policy and procedure manual in six out of seven client records. The facility's policy and procedures manual states case consultations are completed every ninety days unless the client ' s treatment is less than ninety then one is completed.
Client #1 was admitted on January 4, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 4, 2024; however, it was not completed until April 15, 2024.
Client #2 was admitted on January 2, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 2, 2024; however, it was not completed until April 15, 2024.
Client #3 was admitted on November 7, 2023 and was still active at the time of the inspection. A case consultation was due no later than February 7, 2024; however, it was not completed until April 15, 2024.
Client #4 was admitted on October 16, 2023 and discharged on March 4, 2024. A case consultation was due no later than January 16, 2024; however, it was not completed until January 24, 2024.
Client #5 was admitted on August 8, 2023 and was discharged on February 2, 2024. A case consultation was due no later than November 8 2023; however, there is no documentation that one was completed.
Client #7 was admitted on January 23, 2024 and was discharged on March 20, 2024. A case consultation was to be completed prior to discharge if the client was only in treatment less than 90 days, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning June 5th 2024, the Division Director will run the Clinical Forms Audit report monthly and send out emails to all staff of case consultations coming due. The Division Director will ensure that these case consults are completed through monthly chart audits |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project, including a discharge summary in two of four applicable records. The facility's policy and procedure manual states that a discharge summary is completed within seven days of discharge.
Client #4 was admitted on October 16, 2023 and discharged on March 4, 2024. A discharge summary was due no later than March 11, 2024; however, there is no documentation that one was completed.
Client #5 was admitted on August 8, 2023 and discharged on February 2, 2024. A discharge summary was due no later than February 9, 2024; however, there is no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Starting June 5th , the Division Director will run the discharge analysis report weekly and send emails to counselors of outstanding discharge paperwork. After the staff meeting on June 12th, 2024, counselors will be given one hour of paperwork time dedicated to discharge paperwork per week that must be completed |