INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Gate House for Women 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 April 21, 2008.
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Plan of Correction
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709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of client medication records, the facility failed to document medications taken by the clients in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. Several dates were blank for several months with no explanation documented as to why the client did not receive the medication as prescribed.
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Plan of Correction
The Clinical Supervisor will provide training to all staff members responsible for monitoring clients taking medication in the proper documentation by 4/30/2008. To ensure that this documentaion is being completed correctly the Clinical Supervisor monitor medication forms monthly. |
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 ensure that each counselor complete at least 25 clock hours of annual training in one of three records reviewed, #3. One counselor received only 22 hours of training.
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Plan of Correction
The counselor receiving only 22 hours of training during the most previous training year will attend atleast 25 hours of training annually in upcoming training years, as will all counselors. This will be monitred on a quarterly basis through the Clinical Supervisor reviewing the staff training records on a quarterly basis and making training suggestions. |