INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 13, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the Project failed to ensure that each counselor assistant documented to the facility director that they were working toward counselor status in one of one personnel records reviewed.
The findings include:
One employee was required to document to the facility director that he/she was working toward counselor status upon completion of each calendar year. The Project failed to ensure that employee # 4 from the Coatesville Outpatient facility was working toward counselor status.
Employee # 4 from Coatesville Outpatient was hired as a high school level counselor assistant on 6/21/2010. The facility failed to ensure that employee # 4 was working toward counselor status upon completion of the calendar year.
The findings were reviewed with Human Resource and the Facility Director.
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Plan of Correction
Employee #4 from Coatesville has been given a six month deadline to obtain either his CAC or obtain enrollment in a qualifying degree program or face the possibility of termination or transfer to an appropriate position for his current qualifications. This will be monitored on a biweekly basis. |
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 provide hot water.
The findings include:
A physical plant inspection was conducted on May 13, 2014, at approximately 9 AM and 2 PM. The facility failed to provide hot water in four of four of the facility's bathrooms.
The Facility Director confirmed the findings.
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Plan of Correction
Based upon this finding, Gaudenzia, Inc. has repaired the hot water heater to produce the appropriate tempature for hot water. |
709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release client information form to include specific information disclosed and/or failed to comply with the restrictions imposed at 4 Pa. Code 255.5 (b) (1-5), in two of eight client records reviewed.
The findings include:
4 Pa. Code 255.5 (b) 91-5) states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Eight client records were reviewed for documentation of informed and voluntary consent to release client information forms on May 13, 2014. The facility failed to obtain an informed and voluntary consent to release client information form to include specific information disclosed and/or failed to comply with the restrictions imposed at 4 Pa. Code 255.5 (b) (1-5), in client records # 2 and 3.
Client # 2 was admitted to the program on 3/13/14 and was still an active client as of 5/13/14. The record included a consent to release client information form that was signed by the client on 3/4/14. The facility failed to document the specific information disclosed on the consent form.
Client # 3 was admitted to the program on 3/24/14 and was still an active client as of 5/13/14. The record included documentation of the release of urinary drug screen (UDS) results to the client's school guidance counselor on 3/17/14. The facility failed to comply with the restrictions imposed at 4 Pa. Code 255.5 (b) (1-5) by releasing the UDS results to the school.
The Facility Director confirmed the findings.
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Plan of Correction
As a result of this finding, the consents will reflect the PA Code 255.5 that will release only the following to any agency or person or interested stakeholders:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in three of eight client records reviewed.
The findings include:
Eight client records were reviewed on May 13, 2014. The facility failed to document a complete client record that included a record of services provided in client records # 1 and 2, and failed to document a discharge summary in client record # 6.
The findings were reviewed with the Facility Director.
Client # 1 was admitted to the program on 1/16/14 and was still an active client as of 5/13/14. The facility failed to document a record of services provided in client record # 1.
Client # 2 was admitted to the program on 3/13/14 and was still an active client as of 5/13/13. The facility failed to document a record of services provided in client record # 2.
Client # 6 was admitted to the program on 6/1013 and discharged on 12/2/13. The facility failed to document a discharge summary in client record # 6 as of 5/13/14.
The findings were reviewed with the Facility Director.
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Plan of Correction
As a result of this finding, all record of service will be completed at time of filing by Administrative Staff and will be reviewed weekly by Program Director to ensure completeness and accuracy of record of service. Also each discharged chart will be reviewed to ensure completeness of discharge summary regardless of the type of discharge. |