INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 15-16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Together House 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 October 21, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document the qualifications for the position of counselor in one of five personnel records.
The findings include:
Ten personnel records were reviewed on September 15, 2010. Of the ten records reviewed, five were identified as counselors, but the qualifications for the position of counselor were not included in personnel record #5.
Personnel record #5 contained verification of an associate ' s degree from an accredited college with a major in Behavior Health/Human Service, but the resume contained in personnel record #5 did not document at least two years of clinical experience in a health or human service agency.
The resume for personnel #5 documented more than two years of employment in a health or human service agency, but none of the work was clinical.
The facility was cited for non-compliance with this standard during the 6/8/2010 inspection.
|
Plan of Correction
To ensure necessary documentation of employee qualifications are provided the following steps will be followed. Program Director will ensure that necessary documentation of qualifications is placed in the employee hire packet at the time of hire. In addition to this information going into the personnel file at the facility, a copy is also required to be sent to the corporate office prior to the first day of employment. The administrative coordinator will conduct supervisory follow up by contacting the corporate office to confirm each new hire packet has been received with the proper contents. in addition the program director will be responsible for oversight and conduct random audits of personnel files on a monthly baisis to ensure completeness of personnel records at both the facility and corporate office. Full compliance will be met effective 10/29/2010. Personnel record # 5 has been reviewed and as a result this employee has been placed into counselor assistant position. |
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.
|
Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document direct observation supervision notes for counselor assistants.
The findings include:
Ten personnel records were reviewed on September 15, 2010. Of the ten records reviewed, one was identified as a counselor assistant and required direct observation supervision notes. The facility did not document direct observation supervision notes for personnel #10.
An interview with the facility director on September 15, 2010 confirmed that direct observation supervision notes had not been documented for personnel #10.
Employee #10 is the same employee that was cited as employee #9 during the 6/8/2010 inspection.
The facility's plan of correction submitted on 8/20/10 and approved 8/21/10 for the citation issued during the 6/8/10 inspection was as follows:
Program Director will meet with clinical supervisor to review and train on the standards for supervision of all counselor assistants. This will include supervision, direct observation, and the documentation requirements. Clinical supervisor will supervise and document supervison according to standard for personnel file #9 for a period of nine months from the date of this submitted POC before consideration of completed supervision period. Program Director will be responsible for supervisory follow up and Division Director will be responsible for oversight.
|
Plan of Correction
Program Director has met with clinical supervisor to review and train on the standards for supervision of all counselor assistants. This includes supervision,direct observation, and the documentation requirements. Clinical supervisor is supervising and documenting supervision according to standard for personnel file # 10 for a period of nine months from the date of this submitted POC before consideration of completed supervision period. Program Director will be responsible for supervisory follow up and Division Director will be responsible for oversight. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of the personnel records, facility policies and procedures and an interview with the facility director, the facility failed to document feedback on completed training in three of five records.
The findings include:
Ten personnel records were reviewed on September 15, 2010. Of the ten records reviewed, five contained documentation of training completed in 2009, and required documentation of feedback on the completed training. The facility lacked documented feedback on the completed training in records # 3, 4 and 5
The facility ' s policy titled " PLAN FOR COLLECTION OF FEEDBACK ON STAFF TRAINING " states:
" Each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/ Clinical Supervisor. "
An interview with the facility director on September 15, 2010 confirmed that personnel records #3, 4 and 5 did not contain Staff Training Reports.
|
Plan of Correction
Clinical supervisor has conducted a training on the process and policy for completing training feedback forms. The administrative coordinator will provide supervisory follow up by collecting feedback forms the day after the training is held. In addition they will fax a copy to the corporate office. The program director will be responsible for oversight and conduct random audits of personnel files on a monthly basis to ensure completeness of personnel records at both the facility and the corporate office. Full compliance will be met 10/29/2010. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document at least 12 clock hours of training annually for each clinical supervisor in one of two records.
The findings include:
Ten personnel records were reviewed on September 15, 2010. Of the ten records reviewed, two were identified as clinical supervisors and required at least 12 clock hours of training for the 2009 training year. The facility did not document at least 12 hours of training for personnel #3.
The training record for personnel #3 contained 9 hours of training for the 2009 training year.
An interview with the facility director on September 15, 2010 confirmed that personnel record #3 did not contain documentation of at least 12 hours of training for the 2009 training year.
|
Plan of Correction
Program director has conducted a training on the requirements for annual training of a clinical supervisor with appropriate staff. Administrative coordiantor will be responsible for supervisory follow up by conducting monthly audits of all personnel files for required training documentation. Program director will be responsible for oversight and conducting random audits of personnel files to ensure completeness at the facility and the corporate office. Trainings for personnel file # 3 have been scheduled to meet compliance for the upcoming year. Full compliance will be met effective 10/29/2010. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on the review of client records, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in seven of seven client records.
The findings include:
Eight client records were reviewed on September 16, 2010. The facility did not document a treatment plan to include type and frequency of treatment services, as per facility policy, in client records # 1, 2, 3, 4, 5, 6 and 7.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved "
In client record #1, the treatment plan documented on 8/6/10 did not include type and frequency of treatment and rehabilitation services.
In client record #2, the treatment plan documented on 8/9/10 did not include type and frequency of treatment and rehabilitation services.
In client record #3, the treatment plan documented on 9/14/10 did not include type and frequency of treatment and rehabilitation services.
In client record #4, the treatment plan documented on 8/5/10 did not include type and frequency of treatment and rehabilitation services.
In client record #5, the treatment plan documented on 8/14/10 did not include type and frequency of treatment and rehabilitation services.
In client record #6, the treatment plan documented on 9/13/10 did not include type and frequency of treatment and rehabilitation services.
In client record #7, the treatment plan documented on 6/28/10 did not include type and frequency of treatment and rehabilitation services.
The facility's plan of correction submitted on 8/20/10 and approved 8/21/10 for the citation issued during the 6/8/10 inspection was as follows:
All treatment plans in client files will include type and frequency of treatment and rehabilitation services, as stated in the facilities policy titled " PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN " . Included in the action plan will be a statement of the type (individual/group/family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. This standard will be in place by September 3, 2010 and will be monitored by the Program Director and Clinical Supervisor for a period of not less than three months and on a weekly basis and ongoing thereafter.
This deficiency was cited previously on 6/8/10, 6/16/09, 6/18/08, 8/30/07, 9/21/06, 8/4/05 & 10/13/04.
|
Plan of Correction
All treatment files will include type and frequency of treatment in their treatment plans. This means that type will include either, individual/group/family therapy/health education, etc. Frequency will include, daily, 2-3 x weekly, once, ongoing, etc. The program director has conducted and will review monthly with clical staff the requirements for treatment plans. In addition the form has been changed to specifically identify "type and frequency". This standard is in place and full compliance will be bet effective 10/29/2010. Due to the fact that this has been a repeat citation in previous inspections this will be monitored closely. The clinical supervisor will be responsible for supervison for a period of not less than three months and on a weekly basis and ongoing thereafter. The program director will be responsible for oversight. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on the review of client records, the facility failed to document a treatment plan update in five of five client records.
The findings include:
Seven client records were reviewed on September 16, 2010. The facility did not document a treatment plan update, as per facility policy, in client records # 1, 2, 4, 5 and 7.
The facility ' s policy titled " Treatment Plan Reviews " states:
The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted.
In client record #1, the treatment plan update documented on 8/24/10 did not include an assessment of progress.
In client record #2, the treatment plan update documented on 8/24/10 did not include an assessment of progress.
In client record #4, the treatment plan update documented on 9/1/10 did not include an assessment of progress.
In client record #5, the treatment plan was documented on 8/14/10, but a treatment plan update was not documented at the time of inspection on 9/16/10.
In client record #7, the treatment plan update documented on 7/22/10 did not include an assessment of progress.
The facility's plan of correction submitted on 8/20/10 and approved 8/21/10 for the citation issued during the 6/8/10 inspection was as follows:
All client records will have documented treatment plan updates that will include the following as per the facility policy:
The counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter). This review shall include an assessment of the client ' s progress with the goals identified on the initial treatment plan.. This standard will be in place by September 3, 2010 and will be monitored by the Program Director and Clinical Supervisor for a period of not less than three months and on a weekly basis and ongoing thereafter.
This deficiency was cited previously on 6/8/10, 6/16/09, 8/30/07, 9/21/06 & 8/4/05.
|
Plan of Correction
The program director has conducted a training with all clinical staff on the policy and procedure for completing treatment plans and treatment plan updates. This process includes documentation of an assessment of the client's progress with the goals identified on the initial treatment plan. The counselor shall complete a a treatment plan and review and update 30 days after the date of the original individual treatment plan. This review shall include an assessment of the client's progress with the goals identified on the initial treatment plan. This standard is in place and will be in full compliance by 10/29/2010. It will be monitored by the program director and clinical supervisor for a period of not less than three months and on a weekly basis and ongoing thereafter. Division director will be responsible for oversight. |