INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22 through 25, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC, 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 and a plan of correction is due on March 17, 2008.
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Plan of Correction
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704.6(b) LICENSURE Qualification Groups
704.6. Qualifications for the position of clinical supervisor.
(b) A clinical supervisor shall meet at least one of the following groups of qualifications:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 2 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in administration or the human services) or other related field and 4 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person.
(4) 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 and 3 years of clinical experience in a health or human service agency which includes 1 year of working directly with the chemically dependent person. The individual shall also complete a Department approved core curriculum training which includes a component on clinical supervision skills.
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Observations
Based upon review of personnel records on January 22, 2008, the facility failed to ensure that the person hired for the position of clinical supervisor had a degree or credential that met at least one of the groups of qualifications for the position. Employee #4 did not have a degree in a major that met the educational requirements for the position of clinical supervisor.
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Plan of Correction
1. 704.6(b) LICENSURE: 0029
Corrective Action:
The Division Director will assume responsibility for the Inpatient Program by March 1, 2008. The current Program Director will assume clinical and supervisory responsibilities by March 1, 2008.
The Clinical Supervisor who has been determined ineligible will make application to the PCB for certification of a Certified Addiction Counselor (CAC) credential by April 1, 2008. This employee will be required by Gaudenzia DRC management personnel to make application for the CAC Certification Test and past the test within 90 days or by July 2008. The Program Director will monitor the application and testing compliance of this employee.
Persons Responsible:
Division Director, Inpatient Program Director
Timeframe for Completion: April 1, 2008
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based upon review of personnel records on January 22, 2008, the facility failed to ensure that counselor assistants were supervised by a full-time clinical supervisor who meets the qualifications in or (relating to qualifications for the position of clinical supervisor) from January 7, 2008 to present.
Employee #4 did not have a degree in a major that met the educational requirements for the position of clinical supervisor.
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Plan of Correction
2. 704.9(a) LICENSURE: 0045
Corrective Action:
The current Program Director (and Clinical Supervisor at the time of the Audit) assumed responsibility for the Inpatient Program Counselor Assistants as of January 7, 2008. Prior to this date, the Division Director and previous management personnel assigned to the Inpatient Program were qualified according to 704.6 or 704.7 (regarding qualifications for position of clinical supervisor) and supervised the counselor assistants.
The current Program Director will assume clinical and supervisory monitoring responsibilities by March 1, 2008.
Persons Responsible:
Division Director, Inpatient Program Director
Timeframe for Completion: March 1, 2008
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based upon a tour of the physical plant on January 22, 2008, the facility failed to ensure the confidentiality of the identity of Drug and Alcohol clients on the women's unit. The Drug and Alcohol clients on the women's unit were housed on the same floor, without separation, from women in two different programs who were not Drug and Alcohol clients.
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Plan of Correction
3. 709.28(a)(1) LICENSURE: 0271
Corrective Action:
By March 15, 2008 the Inpatient Program females will be housed on an entirely separate floor from other females. This process will be monitored by the Program Director.
Persons Responsible:
Inpatient Program Director
Timeframe for Completion: March 15, 2008
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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 upon a review of client records on January 24 & 25, 2008, the facility failed to ensure that all consents to release information were informed and voluntary. Seven of eight client records reviewed, #1, 2, 3, 4, 5, 6 & 8, required that the revocation be in writing. Client record #7 contained a consent to release information to the probation office which exceeded 4 Pa. Code The consent allowed for the release of the client's drug and alcohol abuse history, aftercare plan and psychosocial evaluation, all of which exceed the limitations imposed at 4 Pa. Code Subsection 255.5(b).
The facility failed to obtain a consent to release information prior to scheduling a meeting with the client and the client's family member in client record #8. The meeting took place five days prior to the completion of a consent to release information form.
The facility failed to ensure that all consents to release information were informed and voluntary. The facility has a contract with a company to dispose of outdated medications and/or medications of clients who have left the facility without taking their medications with them. The facility does not have a Qualified Service Organization Agreement with the company. None of the records reviewed had consent to release information forms where the clients authorized the facility to give client identifying information to the company that collects the medication for disposal, though the medication bottles clearly list client identifying information.
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Plan of Correction
4. 709.28(c) LICENSURE: 0277
Corrective Action:
A confidentiality training and re-training will be conducted for clinical staff on the purpose of informed and voluntary release of information. The release of information form will be revised to include and reflect verbal consent by the client.
The Medical Department will ensure that all clients identifying information will be removed from medication containers before collection and disposal. All medication control systems will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for four (4) months to ensure compliance, completion, and timelines. This process will be monitored by the Nurse Manager and reviewed by the Division Director.
Persons Responsible:
Division Director, Nurse Manager
Timeframe for Completion: March 27th 2008
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709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based upon a review of client records on January 24 & 25, 2008, the facility failed to identify the purpose for the release of information in two of of eight client records reviewed. Client record #2 identified the purpose as "client information in case of emergency". Client record #7 contained a consent to release information form to the probation office, dated 8/31/07, which had no disclosed purpose.
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Plan of Correction
5. 709.28(c)(3) LICENSURE: 0281
Corrective Action:
A confidentiality training and re-training will be facilitated for clinical staff on identification and documentation of the purpose of the release of information form. The release of information form will be revised to reflect clarification and identification of the purpose. All clinical documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines. This process will be monitored by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: March 27, 2008
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709.28(c)(4) 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:
(4) Dated signature of client or guardian.
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Observations
Based upon a review of client records on January 24 & 25, 2008, the facility failed to include complete and correct consent to release information forms in 2 of 8 client records reviewed. Client records #6 contained consents to release information that lacked the signature of the client; they were merely initialed by the client. The facility failed to have the staff person and the client sign or initial date changes that were made to the consent to release information forms in client record #7. Client record #7 contained consents to release information forms that had been pre-dated and then had the dates changed without the clinician and client initialing those date changes.
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Plan of Correction
6. 709.28(c)(4) LICENSURE: 0283
Corrective Action:
A confidentiality training and re-training will be facilitated for clinical staff on release of information completion. No release of information will be in the client files:
1. Without Signatures;
2. Pre-Dated, and;
3. Any changes will be initialed by the staff and client.
All clinical documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: March 27, 2008
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709.28(c)(5) 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:
(5) Dated signature of witness.
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Observations
Based upon a review of client records on January 24 & 25, 2008, the facility failed to ensure that all consents to release information had the signature of a witness. Client record #7 contained a consent to release information to the probation office dated 8/31/07 which had no dated signature of a witness.
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Plan of Correction
7. 709.28(c)(5) LICENSURE: 0285
Corrective Action:
A confidentiality training will be facilitated to train and re-train clinical staff in confidentiality. All consent to release information will be witnessed during the execution of the document/form. All clinical documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: March 27, 2008
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709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
Based upon a review of the facility's policy on the administration of medications and client records on January 22 - 25, 2008, the facility failed to follow the procedures outlined in facility policy for documenting when a client receives their medication, refuses to take their medication, or fails to show up to receive their medications. The medication administration records for two of five clients reviewed, # 7 and 8, were not completed as per facility policy. The records showed days when the medications were not documented as having been received by the clients and there was no documentation on the medication administration record, as per facility policy, that the client refused the medication or failed to show up to take their medications. There was no medication administration record for client record #6 from 9/26/07 to 9/30/07.
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Plan of Correction
8. 709.32(c)(1) LICENSURE: 0319
Corrective Action:
The Nurse Manager will facilitate training and re-training of all direct care and supervisory personnel to follow the procedures outlined in facility medication control policy for documenting when a client receives their medication. The Nurse Manager will train and educate staff on procedures when a client refuses to take their medication or fails to show up to receive their medications.
This training will take place during the week of March 3, 2008 through March 7, 2008. All personnel who monitor medications will be trained by April 7, 2008. All medication control systems will be reviewed during monthly Medication Administrative Reports (MAR) in Continuous Quality Improvement (CQI) meetings and monitored intensively four (4) months for compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director, Nurse Manager
Timeframe for Completion: April 7, 2008
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709.32(c)(5) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(5) Security of drugs.
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Observations
Based upon a review of the facility's policy on the administration of medications, interviews with nursing staff, and a review of client records on January 22 - 25, 2008, the facility failed to follow the procedures outlined in facility policy for the security and accountability of medications.
Facility policy states that at the end of the last medication run of the day, the Nurse doing medication run will check that all medications are present in the correct amount. If any medication is missing, an incident report will be filled out. The missing medication will be reported to the Nursing Manager/Supervisor and Program Director immediately upon discovery. An incident report will be filled out by the staff person discovering the theft.
Should a client get an incorrect medication or dosage of a medication, it must be reported immediately to one of the nurses, the Doctor or an emergency room. The Nursing Manager and the Program Director must also be notified of medication errors. Nurse or staff present at time of the medication error will complete an incident report and insure immediate follow up for the client.
One of five records reviewed, client record #8, showed an unexplained decrease in the amount of cough medicine prescribed to the client that was not documented at the end of the last medication run nor was it reported to the Nursing Manager as soon as staff became aware of the discrepancy. The client reported the discrepancy to staff on October 12, 2007, however it was not reported by the staff person to nursing as per facility policy and nursing had not been made aware of the incident until October 26, 2007.
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Plan of Correction
9. 709.32(c)(5) LICENSURE: 0327
Corrective Action:
The Gaudenzia DRC, Inc. policy on "medication control" will be reviewed by the Nurse Manager and updated as necessary. Systems will be put in place to monitor medication compliance policies and the Nurse Manager will report on "medication control systems" in monthly Medication Administrative Reports (MAR) meetings. These reports will be reviewed and monitored for four (4) months to ensure compliance, completion, and timelines.
The Nurse Manager will facilitate training and re-training of all direct care and supervisory personnel to follow the procedures outlined in facility medication control policy for reporting of medication errors, accidental misuse of medication, wrong dosage taken, missing medication, or medication non-compliance. Staff will be trained, educated, and instructed to notify the Nurse Manager or Program Director "immediately" in such instances. An incident report will be filled out by the staff person discovering the error. All medication control systems will be reviewed during monthly Medication Administrative Reports (MAR) in Continuous Quality Improvement (CQI) meetings and monitored intensively four (4) months for compliance, completion, and timelines by the Nurse Manager.
Persons Responsible:
Division Director, Nurse Manager
Timeframe for Completion: April 7, 2008
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon client records reviewed on January 24 & 25, 2008, the facility failed to
properly document the psychosocial evaluations in three of six client records reviewed. The psychosocial evaluation in one of six client records, #8, was completed 29 days after admission and 28 days after the completion of the comprehensive treatment plan. The comprehensive treatment plan is supposed to be based on the psychosocial evaluation. Two of six client records reviewed, #3 & 7, failed to provide an assessment of the client's support systems.
One of six client records reviewed, #7, failed to provide a composite picture of the client; failed to assess the client's assets/strengths; failed to identify the client's coping mechanisms; and failed to identify negative factors, the clients attitude toward treatment and the clinician's conclusions/impressions.
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Plan of Correction
10. 709.51(b)(6) LICENSURE: 1759
Corrective Action:
A psychosocial evaluation training will be facilitated to train and re-train clinical staff in documenting elements of the psychosocial evaluation providing a composite picture, assessment of strength, identifying coping mechanisms, the client's attitude towards treatment and the clinician's impressions.
Psychosocial Evaluations will be completed per the Gaudenzia DRC Policy & Procedures (Timeframes). All psychosocial documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: April 25th 2008
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based upon a review of client records on January 24 & 25, 2008, the facility failed to provide individualized treatment plans developed with the client. Treatment plans in three of eight client records reviewed, records #1, 3 & 5, were not individualized. Long-term goals, short term goals, action steps and behaviorally defined problems were identical in all three records. Client record #6 lacked a comprehensive treatment plan. The comprehensive treatment plan in client record #7 was not signed by the client. The comprehensive treatment plan for client record #8 had been completed prior to the completion of the psychosocial evaluation. The treatment plan was completed on 9/20/07 and the psychosocial evaluation was completed on 10/30/07.
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Plan of Correction
11. 709.52(a) LICENSURE: 1763
Corrective Action:
A treatment planning training will be facilitated to ensure that all staff are trained and re-trained in treatment plans that are signed by clinical staff and the client, individualized, and completed according to established timeframes.
All treatment plan documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: April 25th 2008
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709.52(a)(1) LICENSURE Short/Long term TX Goals
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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based upon a review of client records on January 24 & 25, 2008, the facility failed to develop individualized short and long-term goals for treatment formulated by both staff and client. Treatment plan goals for clients #1, 3 & 5 were identical in all three records.
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Plan of Correction
12. 709.52(a)(1) LICENSURE: 1765
Corrective Action:
A training and re-training to be facilitated for all staff in developing short and long-term goals for treatment. Staff will be trained to ensure that the goals are individualized and formulated by both staff and client according to Gaudenzia DRC Policy. Gaudenzia DRC will incorporate its previous "treatment plan" form as it meets the standards set by the Division of Drug and Alcohol Licensure.
All treatment planning goals will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: April 25th 2008
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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.
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Observations
Based upon reviews of client records on January 24 & 25, 2008, the facility failed to document the frequency of treatment and rehabilitation services in three of eight client records reviewed, #1, 3 & 5.
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Plan of Correction
13. 709.52(a)(2) LICENSURE: 1767
Corrective Action:
A training will be conducted to ensure that all staff are trained and re-trained in individual treatment and rehabilitation plans that document the frequency of services. Gaudenzia DRC will incorporate its previous "treatment plan" form as it meets the standards set by the Division of Drug and Alcohol Licensure.
All treatment planning documentation regarding frequency of treatment will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: April 25th 2008
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709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based upon a review of client records on January 24 & 25, 2008, treatment plans in four of eight client records reviewed, #1, 3, 5 & 8, failed to include any proposed support services.
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Plan of Correction
14. 709.52(a)(3) LICENSURE: 1769
Corrective Action:
A training will be facilitated to ensure that all staff are trained and re-trained in treatment planning that document and include proposed support services. Gaudenzia DRC will incorporate its previous "treatment plan" form as it meets the standards set by the Division of Drug and Alcohol Licensure.
All treatment planning proposed support services will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: April 25th 2008
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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.
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Observations
Based upon a review of client records on January 24 &25, 2008, the facility failed to provide a written treatment plan update in one of four client records reviewed that required an update, client record #8.
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Plan of Correction
15. 709.52(b) LICENSURE: 1771
Corrective Action:
A training will be facilitated to ensure that all staff are trained and re-trained in providing written treatment plan updates according to established Gaudenzia DRC policy and timelines. Gaudenzia DRC will incorporate its previous "treatment plan" form as it meets the standards set by the Division of Drug and Alcohol Licensure.
All treatment plan updates will be reviewed by the Program Director during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: April 25th 2008
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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
Based upon review of client records on January 24 & 25, 2008, three of eight client records reviewed, #6, 7 & 8 were incomplete. The facility had not yet filed the physicals examinations, some of the progress notes, treatment plans and/or psychosocial evaluations.
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Plan of Correction
16. 709.53(a) LICENSURE: 1791
Corrective Action:
The Program Director will ensure that all client records contain timely physical examinations, progress notes, treatment plans, and psychosocial evaluations.
No records will be closed without a file audit being conducted and approved by the Program Director to ensure completeness. This closed file aspect of care will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and monitored for three (3) months to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Program Director
Timeframe for Completion: April 1, 2008
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709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based upon review of client records on January 24 & 25, 2008, the facility failed to document the name of the medication, dosage and/or frequency of use in three of five client records reviewed, #2, 6 & 7. One of five client records reviewed, #2, indicated in the physical dated 12/6/07 that the client was to continue current medications, however the nursing assessment of 12/4/07 failed to document any medications, dosage or frequency of use.
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Plan of Correction
17. 709.53(a)(2) LICENSURE: 1795
Corrective Action:
The Division Director will ensure that the Nurse Manager accurately completes all nursing assessment forms and documents. All medication forms will include the name, dosage, and frequency of all client medications in the client medical file/chart. All medication control systems will be reviewed during monthly Medication Administrative Reports (MAR) in Continuous Quality Improvement (CQI) meetings and monitored for four (4) months to ensure compliance, completion, and timelines by the Division Director.
Persons Responsible:
Division Director, Nurse Manager
Timeframe for Completion: April 25th 2008
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