INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11-12, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia DRC-Inpatient 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
The facility failed to provide documentation of at least two years experience or the core curriculum training in clinical supervision for employee # 3.
Employee #3 was hired on May 12, 2014 and promoted to current position of clinical supervisor on June 24, 2018. There was no documentation of 2 years experience or the core curriculum training in the employee record.
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Plan of Correction
Employee #3 was removed as Clinical Supervisor, effective 10/1/18.
Inpatient Director and Human Resource Director will ensure that any clinical supervisor for Inpatient will scheduled or have completed the required Department training |
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 provide documentation of a complete and informed consent for client records # 2, 3, 4, 5, 6, and 7. The consent forms provided in the electronic record had a list of agencies including; Pennsylvania Department of Welfare, Community Behavioral Health, In case of emergency, Atlantic Diagnostics, Redwood Toxicology Lab, Pharmatech Inc., Pennsylvania Department of Corrections, Pennsylvania Board of Probation and Parole that did not provide the information that was to be released.
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Plan of Correction
Intake Supervisor will review all consent forms for any and all agencies as well as families by providing what information is being released.
All Consent for client records # 2, 3, 4, 5, 6 and 7 have been corrected and replaced with proper consents to Pennsylvania Department of Welfare, Community Behavioral Health, In case of emergency, Atlantic Diagnostics, Redwood Toxicology Lab, Pharmatech Inc., Pennsylvania Department of Corrections, Pennsylvania Board of Probation and Parole.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to provide documentation that counseling services are being provided according to the individual treatment and rehabilitation plan in.
Client # 2 was admitted on November 10, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on November 13, 2018 indicating 1 individual session weekly and 5 group sessions weekly. Records show only 2 group sessions for the weeks of November 18-24, November 25-December 1, and December 2-8
Client # 3 was admitted on November 14, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on November 21, 2018 indicating 1 individual session weekly and 1 group session weekly. Records show no group sessions the weeks of November 25-December 1 and December 2-8. A progress note for December 4 was in the individual record but is a group session.
Client # 4 was admitted on October 24, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on November 7, 2018 indicating 1 individual session weekly and 1 group session weekly. Records show no individual sessions the weeks of November 11-17 and 18-24 and no group sessions the weeks of November 18-24, 25-December 1, and December 2-8.
Client # 5 was admitted on October 17, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on November 6, 2018 indicating individual session weekly and group session weekly. Records show no individual sessions the weeks of October 21-27, November 4-10, 11-17, and 25-December 1 and no group sessions the week of November 18-24.
Client # 6 was admitted on June 12, 2018 and was discharged on July 30, 2018. A comprehensive treatment plan was developed with the client on June 20, 2018 indicating individual session weekly and group session weekly. Records show no individual sessions the weeks of June 17-23, 24-30, July 1-7, 8-14, and 15-21.
Client # 7 was admitted on July 25, 2018 and was discharged on October 2, 2018. A comprehensive treatment plan was developed with the client on August 8, 2018 indicating individual session weekly and group session weekly. Records show no individual sessions the weeks of September 2-8, 9-15, 23-29.
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Plan of Correction
Clinical Supervisor will review all clinical charts weekly to ensure that the required counseling services are being provided according to treatment plan and rehabilitation plan.
Client #2 - clinical chart was reviewed and all missing individual sessions and groups notes were provided for weeks of November 18-24, November 25-December 1, and December 2-8. Client was discharged on 12/27.
Client #3 - clinical chart was reviewed and all missing individual sessions and groups notes were provided for weeks of November 25-December 1 and December 2-8. A progress note for December 4 was in the individual record but is a group session. Client was discharged on 12/27.
Client #4 - clinical chart was reviewed and all missing individual sessions and group notes were provided for weeks of November 11-17 and 18-24 and no group sessions the weeks of November 18-24, 25-December 1, and December 2-8. Client was discharged 12/26.
Client #5 - clinical chart was reviewed and all missing individual sessions and group notes were provided for weeks of October 21-27, November 4-10, 11-17, and 25-December 1 and no group sessions the week of November 18-24. Client was discharged on 12/19.
Client #6 - clinical chart was reviewed and all missing individual sessions and group notes were provided for weeks of June 17-23, 24-30, July 1-7, 8-14, and 15-21. Client was discharged on 7/30.
Client #7 - clinical chart was reviewed and all missing individual sessions and group notes were provided for the weeks of September 2-8, 9-15, 23-29. Client was discharged on 10/2.
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
The facility failed to provide a complete client record, which is to include referral contact, complete progress notes, client-related correspondence, and follow-up information.
Client # 1 was admitted on October 29, 2018 and was still an active client at the time of the inspection. There was no documentation to support client related correspondence in the client record. A group note on November 7 and 11 was in the client record but did not provide an assessment of the client.
Client # 2 was admitted on November 10, 2018 and was still an active client at the time of the inspection. There was no documentation to support client related correspondence or client referral in the client record. A group note on December 10 and 11 was in the client record but did not provide an assessment of the client.
Client # 3 was admitted on November 14, 2018 and was still an active client at the time of the inspection. There was no documentation to support client related correspondence or client referral in the client record. A group note on December 8 was in the client record but did not provide an assessment of the client.
Client # 4 was admitted on October 24, 2018 and was still an active client at the time of the inspection. There was no documentation to support client related correspondence or client referral in the client record. A group note on November 7 was in the client record but did not provide an assessment of the client.
Client # 5 was admitted on October 17, 2018 and was still an active client at the time of the inspection. There was no documentation to support client related correspondence or client referral in the client record.
Client # 6 was admitted on June 12, 2018 and was discharged on July 30, 2018. There was no documentation to support client related correspondence in the client record.
Client # 7 was admitted on July 25, 2018 and was discharged on October 2, 2018. There was no documentation to support client related correspondence in the client record.
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Plan of Correction
Clinical Supervisor shall conduct weekly audits of random clinical charts to ensure that all charts have completed records including referral contact, completed progress notes, client related correspondence and follow-up information.
Client #1 - clinical chart was reviewed and notes from 11/7 and 11/11 have been corrected with the assessment of the client.
Client #2 - clinical chart was reviewed and notes from 12/10 and 12/11 have been corrected with the assessment of the client.
Client #3 - clinical chart was reviewed and note from 12/8 have been corrected with the assessment of the client.
Client #4 - clinical chart was reviewed and note for 11/7 has been corrected with the assessment of the client.
Client #5 - clinical chart was reviewed and documentation to support client related correspondence and client referral were added to the client record.
Client #6 - clinical chart was reviewed and documentation to support client related correspondence and client referral were added to the client record.
Client #7 - clinical chart was reviewed and documentation to support client related correspondence and client referral were added to the client record. |