INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15 - 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, 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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704.11(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 training records, the facility failed to document HIV/AIDS and TB/STD training in two of two records reviewed on September 15, 2021.
Employee # 3 was hired as a counselor on November 11, 2019. HIV/AIDS and TB/STD training was due to be completed no later than November 11, 2020 but was not documented in personnel training record # 3.
Employee # 9 was hired as support staff on June 4, 2018. HIV/AIDS and TB/STD training was due to be completed no later than June 4, 2020 but was not documented in personnel training record # 9.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These staff members will be scheduled for the HIV/AIDS and TB/STD trainings at the earliest opportunity, and these will be completed no later than 12/31/2021. The Program Director will monitor all staff training files on at least a quarterly basis to ensure that all staff receive required trainings in a timely manner. The Compliance department will review plans of correction within 9 months to ensure full implementation. |
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 training records, the facility failed to document 25 clock hours of annual training required for counselors for the January 1, 2020 - December 31, 2020 training year in one of two records reviewed on September 15, 2021.
Counselor # 3 was hired November 11, 2019. Only 19 clock hours of annual training were documented for the 2020 training year for counselor # 3.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This staff member will be scheduled for additional trainings to meet the full 25 required training hours at the earliest opportunity, and these will be completed no later than 12/31/2021. The Program Director will monitor all staff training files on at least a quarterly basis to ensure that all staff receive required trainings in a timely manner.
The Compliance department will review plans of correction within 9 months to ensure full implementation. |
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.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of seven records reviewed on September 15 - 16, 2021.
Client # 5 was admitted May 21, 2021 and discharged July 7, 2021. A prior authorization for drug and alcohol treatment services was obtained from the funding entity without written consent from the client on May 21, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained regarding the requirement to obtain an informed and voluntary consent from the client for the disclosure of information. This training is scheduled for 10/28/2021. The Program Director will monitor charts to ensure compliance through monthly audits of clinical records, and follow up on any inconsistencies in clinical supervision sessions.
The Quality Assurance department will conduct quarterly program reviews to include monitoring of consent forms, and the Compliance department will review the plan of correction within 9 months to ensure full implementation. |