INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27 through 30, 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 December 2, 2008.
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Plan of Correction
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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 eight personnel records on October 27, 2008, the facility failed to document a minimum of 25 hours of training regardless of number of hours worked for individuals performing the duties of counselor in one of one records where required.
Findings:
The facility did not document a minimum of 25 training hours for the 2007 training year in personnel record # 7.
Personnel record # 7 documented only 13 hours of training for the 2007 training year.
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Plan of Correction
The Program Director and Human Resources Manager will ensure that all individuals performing the work of counselors receive a minimum of 25 hours of training per year. The Human Resources Manager will review all counselor training hours semi-annually to ensure compliance with this standard.
Persons Responsible:
Division Director, Human Resources Manager, Inpatient Program Director
Timeframe for Completion: Ongoing
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the facility ' s 2007-2008 Annual Report and an interview with the facility director on October 28, 2008, the facility failed to document a complete report to include a financial statement of income and expenses for the fiscal year of 2007-2008.
Findings:
The facility did not include a financial statement of income and expenses in their 2007-2008 Annual Report. The facility documented a financial statement of income and expenses in a separate section of their policy and procedures manual but not in the actual Annual Report.
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Plan of Correction
The Division Director under the supervision of the Executive Director will ensure that the agency's actual Annual Report contains a financial statement of income and expenses within the original Annual Report as outlined in the standard.
Persons Responsible:
Division Director
Timeframe for Completion: December 15, 2008
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709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the facility ' s 2007-2008 Annual Report and an interview with the facility director on October 28, 2008, the facility failed to document a complete report to include a statement disclosing the names of officers, directors and principal shareholders.
Findings:
The facility did not include a statement disclosing the names of officers, directors and principal shareholders in their 2007-2008 Annual Report. The facility documented the names of officers, directors and principal shareholders in a separate section of their policy and procedures manual but not in the actual Annual Report.
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Plan of Correction
The Division Director under the supervision of the Executive Director will ensure that the agency's actual Annual Report documents the names of officers, directors, and principal shareholders within the original Annual Report as outlined in the standard.
Persons Responsible:
Division Director
Timeframe for Completion: December 15, 2008
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of ten client records and administrative documentation on October 30, 2008, the facility failed to demonstrate efforts towards informing clients of the complete list of client rights in seven of seven records where required.
Findings:
The facility failed to document a complete list of client rights in the client handbook or client signoff of rights form in client records # 1, 2, 3, 4, 5, 6, and 10.
The client handbook did not include:
(1)The project director may temporarily remove portions of the records prior to the inspection by the client if he/she determines that the information may be detrimental if presented to the client.
(2)The client shall have the right to appeal a decision limiting access to his records to the project director.
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Plan of Correction
The Division Director will review and update the complete list of client rights in the client handbook and/or sign-off sheet that includes the statement(s): (1) The Project Director may temporarily remove portions of the records prior to inspection by the client if he/she determines that the information may be detrimental if presented to the client; (2) The client shall have the right to appeal a decision limiting access to his/her records to the project director.
Persons Responsible:
Division Director
Timeframe for Completion: December 15, 2008
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on an inspection conducted October 27-30, 2008, the facility failed to demonstrate a data collection and record keeping system that allows for the efficient retrieval of data.
Findings:
On 10/29/2008 at 9:00 AM the licensing specialist was presented with an incomplete list of active clients. At this time the complete list of active clients was requested, but this list was not presented to the licensing specialist until 9:35 AM. At this time the licensing specialist requested six active client records for review. Two of the six records were received at 10:00 AM, but the remainder of the requested records was not received until 12:00 PM.
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Plan of Correction
The Division Director and Program Director will ensure that all current and future Data Collection Systems are able to efficiently retrieve timely, accurate and complete client information for review by licensing specialist
Persons Responsible:
Division Director, Program Director
Timeframe for Completion: November 27, 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 on a review of ten client records on October 29, 2008, the facility failed to document psychosocial evaluations with the counselor's evaluation of the client's support systems, assets/strengths and negative factors in eight of eight client records requiring them.
Findings:
The facility did not document complete psychosocial evaluations in client records #1, 2, 3, 4, 5, 6, 7 and 10.
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Plan of Correction
A record-keeping training to include the Psychosocial Evaluation will be facilitated to train and re-train clinical staff in documenting elements of the psychosocial evaluation providing the counselor's evaluation of the client's support systems, assets/strengths, and negative factors.
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:
Executive Director, Division Director, & Program Director
Timeframe for Completion: January 30, 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 on a review of ten client records on October 29, 2008, the facility failed to document a comprehensive treatment plan in three of eight client records requiring them.
Findings:
The facility did not document a comprehensive treatment plan in client records #1, 4 and 7.
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Plan of Correction
A record-keeping training to include the a review of treatment planning standards will be facilitated to ensure that all staff are trained and re-trained in treatment plans that are completed according to established timeframes, and placed in the client records as required by the standard.
All treatment plan documentation and compliance timeframes 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:
Executive Director, Division Director, & Program Director
Timeframe for Completion: January 30, 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 on a review of ten client records on October 29, 2008, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan on the treatment plan update in two of two client records where due.
Findings:
The facility did not document complete treatment plan updates in client records #3 and 5.
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Plan of Correction
All treatment planning shall be reviewed and updated at least every 30 days. Treatment plans will be updated every 14 days for projects where the treatment regime is less than 30 days.
All treatment plan update documentation and compliance timeframes 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: January 30, 2008
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of ten client records on October 29, 2008, the facility failed to document a record of services provided in four of ten client records reviewed.
Findings:
The facility did not document a record of services provided in client records #2, 7, 8 and 9.
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Plan of Correction
All record of service documentation and compliance timeframes 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:
Executive Director, Division Director
Timeframe for Completion: January 30, 2008
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of ten client records on October 29, 2008, the facility failed to document case consultation notes for two of three client records where due.
Findings:
The facility did not document case consultation notes for client records #3 and 5.
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Plan of Correction
All client records case consultation documentation and compliance timeframes 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: January 30, 2008
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709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of ten client records on October 29, 2008, the facility failed to document a discharge summary in two of four client records where due.
Findings:
The facility did not document a discharge summary in client records #7 and 9.
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Plan of Correction
All client records discharge summary documentation and compliance timeframes 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: January 30, 2008
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of ten client records on October 29, 2008, the facility failed to document follow-up information in two of two client records where due.
Findings:
The facility did not document follow-up information in client records #7 and 9.
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Plan of Correction
The system for follow-up will be reviewed with all clinical staff responsible for documenting follow-up information.
All client records follow-up documentation and compliance timeframes 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: January 30, 2008
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