INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 4 - 5, 2017 by staff from the Division of Drug and Alcohol 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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704.7(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
The facility failed to ensure that each counselor meets the qualifications for the position.
Employee #7 was hired as a counselor on 9-27-2017, but does not meet the experiential qualifications of the counselor position.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Division Director will review the required qualifications for counselor positions by 11/10/2017 and ensure all future potential employees for counselor positions meet the minimum requirements prior to hire.
Division Director will call DDAP and review any potential hires, that have experience that is questionable, to ensure they do meet experiential qualifications.
Division Director will review counselor educational and experiential requirements with all Program Directors, Program Supervisors, and Clinical Supervisors by 11/21/2017.
Employee #7 will be provided appropriate supervision by the Program Director/Clinical Supervisor as required for counselor assistants until the employee fits the correct experience to be moved into a counselor role/position. |
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
The facility failed to document a complete release of information form prior to disclosure in four of seven client records reviewed on October 4 - 5, 2017.
Client #1 - Admitted to treatment on 3-13-2017 and was discharged on 6-9-2017. A release of information for the purpose of an emergency contact, signed on 3-1-2017 was blank for the person / agency. A release of information for the purpose of coordination of care, signed on 3-1-2017 was blank for the person / agency.
Client #4 - Admitted to treatment on 6-30-2017 and was discharged on 9-25-2017. The record included a letter regarding another client. The letter was dated 8-9-2017 and included another clients name and information.
Client #5 - Admitted to treatment on 6-9-2017. A release of information for another provider was signed on 7-10-2017, and did not indicate the specific information to be disclosed. A release of information for the purpose of an emergency contact, signed on 6-9-2017, was blank for the person / agency.
Client #7 - Admitted to treatment on 7-14-2017. The client record included an encounter/contact form for another client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will meet with all staff and complete a training on documenting releases of information appropriately by 11/21/2017.
Program Director will meet with all program staff and discuss confidentiality and the importance of following all guidelines related to confidentiality by 11/21/2017.
Program Director/Clinical Supervisor will complete monthly chart audits looking at releases of information to ensure they are being completed appropriately. These chart audits will begin November 2017.
Program Director/Clinical Supervisor will report their chart audit results in the agency quality improvement meeting every month starting on 12/20/2017. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in seven of seven client records reviewed on October 4-5, 2017.
There was no documentation that the client was informed that the project, facility of clinical director may temporarily remove portions of the records prior to the inspection, if determined detrimental; reason for removal would be documented in the client's record; client has a right to appeal the decision to remove information and that the client had the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record in client records # 1, 2, 3, 4, 5, 6, and 7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 11-29-2016 annual inspection.
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Plan of Correction
Division Director will review and adjust agency policy as needed to ensure all required client rights are listed in the client rights that are reviewed with clients upon admission. Division Director will complete this review by 11/14/2017.
Division Director will review agency policy/client rights with the Program Director by 11/17/2017.
Program Director will review updated policy/client rights with all staff by 11/21/2017.
Staff will begin using updated policy/client rights with all clients starting 11/22/2017.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to document a treatment plan update in two of four client records reviewed on October 4-5, 2017.
Client #2 was admitted to treatment on 3-3-2017 and was discharged on 9-14-2017.
A treatment plan was completed on 4-19-2017. A review/update was due by 6-19-2017 and 8-19-2017. There was no documentation of a treatment plan update in record #2.
Client #5 was admitted to treatment on 6-9-2017. A treatment plan was completed on 7-10-2017. A review/update was due by 9-10-2017. There was no documentation of a treatment plan update in record #5.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will meet with all clinical staff and review required time frames to complete treatment plan updates. this meeting will occur by 11/21/2017.
Program Director/Clinical Supervisor will complete monthly chart audits to ensure treatment plan updates are completed in a timely manner. These monthly chart audits will begin in November 2017.
Program Director/Clinical Supervisor will report the monthly chart audit results in the agency quality improvement meeting monthly beginning 12/20/2017. Any continued issues with treatment plan updates will be discussed in the agency QI meeting and solutions identified as needed. |
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
The facility failed to document a complete client record in six of seven client records reviewed on October 4-5, 2017.
Client # 1 - Admitted to treatment on 3-13-2017 and was discharged on 6-9-2017. Missing documentation of progress notes for sessions listed on the record of service.
Client # 2 - Admitted to treatment on 3-3-2017 and was discharged on 9-14-2017. Missing documentation of progress notes for sessions listed on the record of service. Missing a discharge summary.
Client #4 - Admitted to treatment on 6-30-2017 and was discharged on 9-25-2017. Missing documentation of progress notes for sessions listed on the record of service. Missing a record of service entry for 9-18-2017.
Client #5 - Admitted to treatment on 6-9-2017. Missing documentation of progress notes for sessions listed on the record of service. Missing a psychosocial evaluation.
Client #6 - Admitted to treatment on 7-25-2017. Missing documentation of progress notes for sessions listed on the record of service.
Client #7 - Admitted to treatment on 7-14-2017. Missing documentation of progress notes for sessions listed on the record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will conduct a training on clinical documentation including required time frames for treatment plans, treatment plan updates, record of service, progress notes, biopsychosocial and assessments, case consults and any other required clinical documentation by 11/30/2017. All clinical staff will attend this training.
Program Director/Clinical Supervisor will complete monthly chart audits beginning in November 2017 to ensure clinical documentation is completed in a timely and effective manner.
Program Director/Clinical Supervisor will report chart audit findings in the agency monthly quality improvement meeting starting on 12/20/2017. Any continued clinical documentation issues will be discussed in a solution focused manner during this meeting. |