INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 11, 2009 licensure renewal inspection. The follow-up inspection was conducted on November 18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia, Inc. People with Hope/ Short-Term Program 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 17, 2009.
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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 personnel records, the facility failed to document at least 25 clock hours of training annually in one of one personnel records.
Findings:
Five personnel records were reviewed on June 11-12, 2009. One of the personnel records reviewed was a counselor, requiring documentation of 25 clock hours of training. The facility only had documentation for 18 hours of the required 25 hours for the 2008 training year in personnel record # 3.
This cannot be re-evaluated until next licensing inspection. Please resubmit the original plan of correction.
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Plan of Correction
Project was not in compliance with the standard with counselors meeting training requirements as outlined in 704.11(f)(2).
Program Director and clinical supervisor will formulate Individual Training Plans annually for each staff including clinical counselors by January 31, 2010 with emphasis on Clinical Record Keeping, Treatment Planning, Pharmacology, Ethics,Relapse Prevention and Counseling Techniques Division Director and/or Program Director will ensure the required training hours trainings of at least 25 hours are completed in a timely manner in 2010.The Administrator Coordinator will monitor personeel charts weekly to check the clinical staff required training hours on a weekly basis and report status to Program Director to assess the need for enrollment into trainings to ensure each counselor is meeting training reqirements. |
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 on a review of seven client records, the specific information disclosed to the funding source exceeded 4 Pa. Code, Subsection 255.5(b) in that the consent to release information form in 4 out of 7 client records reviewed. Additionally, the facility failed to document who information was being disclosed in 2 out of 7 records.
Findings:
Seven client records were reviewed on November 18, 2009. Consent to release information forms were reviewed in six client records. The the specific information disclosed to the funding source exceeded 4 Pa. Code, Subsection 255.5(b) in client records # 1, 3, 4, and 5. The facility failed to indicate who the information was going to be disclosed to in client records # 2 and 6. The facility failed to document any consent to release forms in client record #7.
Client record #1 documented a signed consent on 10/27/2009 to allow the facility to release information to a funding source, a government agency and an insurance company, the following information " medical, urines, medication, psych evals, psych notes."
Client record #2 had documented a signed consent by a client on 10/27/2009. However, the facility failed to indicate who the release was to and what was being released.
Client record #3 had a consent to release form signed on 11/4/2009 for FIR which allowed the facility to release "any and all information pertaining to the client's treatment." Additionally, a signed consent for CBH dated 11/4/2009, a government agency and an insurance company, allowed the facility to release "medication, urines, and psych eval/notes."
Client record # 4 had a consent to release signed for CBH which allowed the facility to release " medical status, discharge and aftercare, and referral." This consent was also not dated. Additionally, there was a release signed in this record for DHS on 8/28/2009 which allowed the facility to release the following information "intake, medical, mental, discharge, and aftercare."
Client record # 5 had a consent to release signed 8/13/2009 for CBH which allowed the facility to release " medical, psych status, referral and discharge status."
Client record # 6 had a signed consent dated 10/19/2009 that does not disclose who the information is being released to. The information that is being permitted to be released is "any and all information pertaining to the client's treatment."
Client record # 7 failed to have any consent to release information forms signed for the funding source/ referral source.
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Plan of Correction
Project was not in compliance with the standards due to the informed and voluntary consent from the client noting specific purpose of disclosureand exceeding 4 Pa.Code, Subsection 255.5(b) in client records as outlined in 709.28(c)(3).
Porgram Director and/or Clinical Supervisor will conduct an inservice training on the specifics of releasing the following five components 1.Treatmnt Status 2. Prognosis 3. Nature of Project 4. Brief Progress Statement 5. Brief Relapse Potential Statement by January 29,2010.Division Director and Program Director will follow up with Clinical Supervisor & counselors to ensure consent forms are being filled out accurately in bi-weekly chart audits. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of seven client records, all of which were reviewed for completion of physical examinations, the facility failed to document a physical examination within seven days from the date of admission as per facility policy and procedure in five of seven client records.
Findings:
Facility policy titled "PHYSICAL EXAMINATION LABORATORY STUDIES", dated January, 2009, stated:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend."
Seven client records were reviewed on November 18, 2009. Physical examinations were reviewed in seven client records. The facility did not document a physical examination within seven days of admission, as stated in the project 's policy manual, in client record # 1. The client arrived to the program on 10/27/2009. The physical examination was documented on 11/4/2009 which was two days late.
Client record # 3 was admitted into the program on 11/4/2009. The facility failed to document a physical on this client as of the date of the inspection.
Client record # 4 was admitted into the program on 8/20/2009. The facility failed to document the date that the physical examination took place. Therefore there is no way to know if the examination was completed within the required timeframe.
Client record #5 was admitted into the program on 8/13/2009. The facility failed to document the date that the physical examination took place. Therefore there is no way to know if the examination was completed within the required timeframe
Record # 6 was admitted into the program on 10/19/2009. The physical examination was documented on 10/27/2009 which was two days late.
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Plan of Correction
Project was not in compliance with the standard due to physical examinations not documented as part of the Intake & Admissions processes in five of seven client records reviewed as required within seven days of admission as outlined in 709.51(b)(5).
Porgram Director has scheduled a compliance findings update meeting with Nursing Manager and Division Director to set up a viable system with the on site nursing staff by February 28,2010 to ensure all physical examinations are completed by the agency's attending physician or the client's primary care physician within a week of client's admission date and document physical examinations as completed to be placed in each client's charts by the program's nursing staff. This system will be monitored by Nursing Manager within first week of client's admit date and followed up by Program Director to report ongoing progress updates to Division Director.
Nursing Program Manager has a clip board system that is monitored weekly to ensure physical examinations are being completed within 7 seven days of admission and systen will be audited weekly by Nursing Manager to meet complaince standards. |
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 the review of client records, the facility failed to document an individual treatment and rehabilitation plan in four of seven client records. Additionally, the individual treatment plan was not signed by the client and/or counselor in two of seven client records.
The findings include:
Seven client records were reviewed on November 18, 2009. Individual treatment and rehabilitation plans were required in seven client records. The individual treatment and rehabilitation plans are due within 72 hours of the client's admission according to a phone interview with the facility director on November 20, 2009. The facility failed to document individual treatment and rehabilitation plans in client records # 2, 3, 6, and 7. Additionally, client record # 1 and # 4 the facility failed to have the client and/or counselor sign and date the treatment plan. There was documentation that verified that the client had reviewed and helped to develop their treatment plan.
Client record # 1 failed to have the client sign and date the individual treatment and rehabilitation plan that was dated 10/29/2009 on the front of the form. The treatment plan is to be developed with the client. Since the client did not sign this treatment plan there is no way to know if the client was involved with the development of this treatment rehabilitation plan.
Client record # 2 was admitted on 10/27/2009. The facility failed to document an individual treatment and rehabilitation plan for this client.
Client record # 3 was admitted on 11/4/2009. The facility failed to document an individual treatment and rehabilitation plan for this client.
Client record # 4 had a treatment plan in the file that was signed by the client but it was not dated. Therefore there is no way to ensure that this plan was provided to the client within the required timeframe. The date on the front of the treatment plan was 8/24/2009.
Client record # 6 was admitted on 10/19/2009. The facility failed to document an individual treatment and rehabilitation plan for this client.
Client record # 7 was admitted on 10/9/2009. The facility failed to document an individual treatment and rehabilitation plan for this client.
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Plan of Correction
Project was not in compliance with the standard due to the review indicating that there was not an individual treatment and rehabilitation plan in four of the seven client records as outlined in 709.52(a).
Porgram Director and Clinical Director plan to conduct an inservice to address Comprehensive Treatment Plans and Rehabilitation Plans which will emphasize signing of the documents by all designated parties including clients & counselors as well as dates by February 28, 2010.
Program Director and Clinical Supervisor will monitor complaince through weekly chart reviews and provide topic related feedback to counselors in bi-weekly group supervison & individual supervision on an ongoing basis. Division Director will be provided follow up complaince update reports to enure statndards are contining to be met. |
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 seven client records the facility failed to document a treatment plan update in five of seven client records.
Findings:
Seven client records were reviewed on November 18, 2009. The facility failed to document treatment plan updates in five of seven records reviewed. According to the facility policy, treatment plan updates are required every 14 days for clients in the short-term program and every 30 days for clients in the long term program. The facility did not document a treatment plan update to include an assessment of the client's progress in relationship to the stated goals on the comprehensive treatment plan in client records # 4 and 5. Additionally, the facility failed to document treatment plan updates in client records #1, 2, 4, 5, and 7.
Client record #1 required a treatment plan update. The facility failed to document the treatment plan update that was due on 11/13/2009.
Client record #2 failed to have a treatment plan update documented in the file.
Client record #4 required a treatment plan update. The facility failed to document the treatment plan update that was due on 10/20/2009. Additionally, the facility failed to include an assessment of the client's progress in the treatment plan dated 9/20/2009.
Client record #5 failed to document treatment plan updates that were due on 10/16/2009 and 11/16/2009. Additionally, the treatment plan dated 9/17/209 did not include an assessment of the client's progress nor was this treatment plan update signed by the client..
Client record # 7 failed to document a treatment plan update that would have been due on November 11, 2009.
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Plan of Correction
Project was not in compliance with the standard due to the review indicating that treatment plans & rehabilitation plans were not updated at least every 30 days or 15 days as mandated in five of the seven records as outlined in 709.52(b).
Program Director and Clinical Supervisor plan to conduct an inservice training to highlight the correct & concise completion of updates by February 28, 2010.
Program Director and Clinical Supervisor will monitor ongoing compliance through weekly chart reviews and provide topic related feed back to counselors in bi-wekly group supervision and individual supervision. Division Director will be provided follow up compliance update reports to ensure standards are contining to be met. |
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 the review of client records the facility failed to have a complete client record which included a record of services provided.
The findings include:
Seven records were reviewed on November 18, 2009. Based on review of the client records six out of seven records failed to have a complete client record which included a record of services provided specifically in client records # 1, 2, 4, 5, 6, and 7.
The facility failed to document any record of services in client record # 1, 2, 6, and 7.
Client record # 4 had a record of service, however, the facility failed to document any services after October 2, 2009. As of the date of review the patient was in treatment.
Client record # 5 had a record of service, however, the facility failed to document any record of service after October 1, 2009. As of the date of review the patient was in treatment.
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Plan of Correction
Project was not in compliance with the the standard due to Record of Services not being complete in six of the seven client records reviewed as outlined in 709.53(a)(3). Program Director and Clinical Supervisor will facilitate an inservice training on the concise completion of Records of Services by February 28, 2010. Program Director and Clinical Supervisor will monitor ongoing compliance by conducting ongoing weekly chart audits to be able to present topic related feedback in clinical group supervision and individual supervision.Division Director will be given follow up compliance update reports to ensure standards are being met. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on the review of client records ,the facility failed to document progress notes in four of seven client records.
The findings include:
Seven records were reviewed on November 18, 2009. Progress notes were required in seven client records. The facility failed to provide documentation of progress notes in client records #1, 2, 6 and 7.
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Plan of Correction
Project was not in compliance with the standards due to progress notes not being in four of the seven client records reviewed as outlined in709.53(a)(5). Program Director and Clinical Supervisor will facilitate an inservice training on Clinical Record Keeping to highlight accurate comphrensive completion of progress notes by March 30, 2010. Program Director and Clinical Director will conduct weekly chart reviews to give clinical topic related feed back to counselors in group supervisions and individual supervisions. Division Director will be provided follow up compliance update reports to ensure standards are being met. |