INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection,Gaudenzia Outpatient 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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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant policies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis. These policies will be revised and approved by July 31st, 2012.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner. The Financial Audit for Fiscal Year 2011-2012 will be completed within 6 months after the June 30th close of Gaudenzia's fiscal year (by December 31st, 2012) as per Chapter 709.25(a).
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document the clients' medical history as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of medical histories:
" Procedure for Intake Documentation of Histories:
Data relevant to the client's personal history will be collected and documented in the client's record on specific history forms. Interviews will be conducted by the counselor or nurse responsible for the intake process and shall be completed during the client's first individual counseling session.
Ten client records requiring documentation of medical histories were reviewed on May 23, 2012. Five of ten client records, specifically #'s 3, 4, 5, 9, and 10 had medical histories that were either missing or undated.
Client #3 was admitted to treatment on February 15, 2012. The client's last day of counseling was on May 16, 2012. The medical history was not documented as of the date of inspection.
Client #4 was admitted to treatment on November 19, 2011 and was active as of the date of inspection. The record representing client #4 did have documentation of a medical history, however, it was undated.
Client #5 was admitted to treatment on January 5, 2012 and was active as of the date of inspection. The record representing client #5 did have documentation of a medical history, however, it was unsigned and undated.
Client #9 was admitted to treatment on October 22, 2011 and discharged on January 21, 2012. The medical history was not documented as of the date of inspection.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. The record representing client #10 did have documentation of a medical history, however, it was unsigned and undated.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
A review in-service will be held on June 29, 2012 to refresh clinical staff on treatment management procedures specific to the bio-psychosocial process and timelines; specifically completion within three sessions.
Weekly administrative meetings are scheduled to review procedures and effectiveness of filing clinical documentation.
The Program Supervisor and Clinical Supervisor will monitor the timeliness of the bio-psychosocial completion through the monthly CQI process.
Clinical staff will be monitored by the Program Supervisor and the Clinical Supervisor in monthly supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting.
Completion Date:
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document the clients ' drug/alcohol history as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of drug/alcohol histories:
" Procedure for Intake Documentation of Histories:
Data relevant to the client's personal history will be collected and documented in the client's record on specific history forms. Interviews will be conducted by the counselor or nurse responsible for the intake process and shall be completed during the client's first individual counseling session ...The interview includes the following elements:
- Bio-Psycho-Social which includes a drug/alcohol history and a personal history; i.e. work, family history, financial history, legal history, education history, sexual history, recreational history, military history, social history, cultural history and spiritual history "
Ten client records requiring documentation of drug/alcohol histories were reviewed on May 23, 2012. Five of ten client records, specifically #'s 3, 4, 5, 9, and 10 had drug/alcohol histories that were either missing or undated.
Client #3 was admitted to treatment on February 15, 2012. The client's last day of counseling was on May 16, 2012. The drug/alcohol history was not documented as of the date of inspection.
Client #4 was admitted to treatment on November 19, 2011 and was an active client as of the date of inspection. The record representing client #4 did have documentation of a drug/alcohol history, however, it was undated.
Client #5 was admitted to treatment on January 5, 2012 and was an active client as of the date of inspection. The record representing client #5 did have documentation of a drug/alcohol history, however, it was unsigned and undated.
Client #9 was admitted to treatment on October 22, 2011 and discharged on January 21, 2012. The drug/alcohol history was not documented as of the date of inspection.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. The record representing client #10 did have documentation of a drug/alcohol history, however, it was unsigned and undated.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
A review in-service will be held on June 29, 2012 to refresh clinical staff on treatment management procedures specific to the bio-psychosocial process and timelines; specifically completion within three sessions.
Weekly administrative meetings are scheduled to review procedures and effectiveness of filing clinical documentation.
The Program Supervisor and Clinical Supervisor will monitor the timeliness of the bio-psychosocial completion through the monthly CQI process.
Clinical staff will be monitored by the Program Supervisor and Clinical Supervisor in monthly supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document the clients' personal history as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of personal histories:
" Procedure for Intake Documentation of Histories:
Data relevant to the client's personal history will be collected and documented in the client's record on specific history forms. Interviews will be conducted by the counselor or nurse responsible for the intake process and shall be completed during the client's first individual counseling session ...The interview includes the following elements:
- Bio-Psycho-Social which includes a drug/alcohol history and a personal history; i.e. work, family history, financial history, legal history, education history, sexual history, recreational history, military history, social history, cultural history and spiritual history "
Ten client records requiring documentation of personal histories were reviewed on May 23, 2012. Five of ten client records, specifically #'s 3, 4, 5, 9, and 10 had personal histories that were either missing or undated.
Client #3 was admitted to treatment on February 15, 2012. The client's last day of counseling was on May 16, 2012. The personal history was not documented as of the date of inspection.
Client #4 was admitted to treatment on November 19, 2011 and was an active client as of the date of inspection. The record representing client #4 did have documentation of a personal history, however, it was undated.
Client #5 was admitted to treatment on January 5, 2012. The record representing client #5 did have documentation of a personal history, however, it was unsigned and undated.
Client #9 was admitted to treatment on October 22, 2011 and discharged on January 21, 2012. The personal history was not documented as of the date of inspection.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. The record representing client #10 did have documentation of a personal history, however, it was unsigned and undated.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
A review in-service will be held on June 29, 2012 to refresh clinical staff on treatment management procedures specific to the bio-psychosocial process and timelines; specifically completion within three sessions.
Weekly administrative meetings are scheduled to review procedures and effectiveness of filing clinical documentation.
The Program Supervisor and Clinical Supervisor will monitor the timeliness of the bio-psychosocial completion through the monthly CQI process.
Clinical staff will be monitored by the Program Supervisor and Clinical Supervisor in monthly supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's composite picture, assets and strengths, problems and needs, support systems, and coping mechanisms or failed to document a psychosocial evaluation at all.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of psychosocial assessments:
"Psychosocial Assessment:
Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client ' s strengths, abilities and preferences...
The assessment shall be submitted promptly to the Clinical Supervisor for review and signature...within 3 individual sessions for outpatient."
Ten client records were reviewed for psychosocial evaluations on May 23, 2012. Five out of ten client records lacked documentation of a psychosocial evaluation, specifically records # 3, 6, 7, 9, and 10; Additionally, two out of ten client records lacked documentation of a psychosocial assessment that included a clinical assessment of the clients' assess/strengths, support systems, coping mechanisms, negative factors that can affect treatment, and attitude toward treatment, specifically client records # 4 and 5.
Client #3 was admitted to treatment on February 15, 2012. The client's last day of counseling was on May 16, 2012. As of the date of inspection, there was no documentation of a psychosocial assessment for client #3.
Client #4 was admitted to treatment on November 19, 2011. The psychosocial assessment was undated and did not include the client's composite picture, a clinical assessment of the client ' s assets and strengths, support systems, coping mechanisms, and negative factors that can affect treatment.
Client #5 was admitted to treatment on January 5, 2012. The psychosocial assessment was completed on December 30, 2011 and did not include the client's composite picture, a clinical assessment of the client ' s assets and strengths, negative factors that can affect treatment, and attitude towards treatment.
Client #6 was admitted to treatment on January 23, 2012. The psychosocial assessment was due by March 6, 2012. As of the date of inspection, there was no documentation of a psychosocial assessment for client # 6.
Client #7 was admitted to treatment on December 3, 2011 and discharged on March 23, 2012. The psychosocial assessment was due by January 10, 2012. As of the date of inspection, there was no documentation of a psychosocial assessment for client #7.
Client #9 was admitted to treatment on October 22, 2011 and discharged on January 21, 2012. The psychosocial assessment was due by December 23, 2011. As of the date of inspection, there was no documentation of a psychosocial assessment for client #9.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. The client ' s last day of counseling was on November 9, 2011. As of the date of inspection, there was no documentation of a psychosocial assessment for client #10.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
A review in-service will be held on June 29,2012 to refresh clinical staff on treatment management procedures and licensing standards specific to the bio-psychosocial and assessment completion. More specifically the inservice will address the client's composite picture, a clinical assessment of the client ' s assets and strengths, support systems, coping mechanisms, and negative factors that can affect treatment.
The Program Supervisor and Clinical Supervisor will monitor the timeliness and standard compliance through the monthly CQI process.
Clinical staff will be monitored by the Program Supervisor and the Clinical Supervisor in monthly supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 the facility's policies and procedures and client records, the facility failed to develop individual treatment and rehabilitation plans as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of treatment plans.
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) by the second or third counseling outpatient appointment...."
Nine client records requiring documentation of individualized treatment plans were reviewed on May 23, 2012. Three out of nine client records did not have documentation of a comprehensive treatment plan, specifically #'s 6, 7, and 9.
Client #6 was admitted to treatment on January 23, 2012. The comprehensive treatment plan was due by March 6, 2012. As of the date of inspection, there was no documentation of a comprehensive treatment plan for client # 6.
Client #7 was admitted to treatment on December 3, 2011 and discharged on March 23, 2012. The comprehensive treatment plan was due by January 10, 2012. As of the date of inspection, there was no documentation of a comprehensive treatment plan for client #7.
Client #9 was admitted to treatment on October 22, 2011 and discharged on January 21, 2012. The comprehensive treatment plan was due by December 23, 2011. As of the date of inspection, there was no documentation of a comprehensive treatment plan for client #9.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on April 21, 2011 and May 17, 2011.
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Plan of Correction
An in-service will be held by the Program Supervisor on July 20, 2012 to address timelines and steps required to complete the comprehensive treatment plan. All clinicians will be directed to complete the comprehensive treatment plan by the third session. T All staff will be reminded that the treatment plan is to be client driven and is to reflect strenghts and concerns identified in the client assessment.
Weekly administrative meetings are scheduled to review procedures and effectiveness of filing clinical documentation.
Clinical staff will be monitored in regular supervisory sessions by the Program Supervisor and the Clinical Supervisor to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
Program Supervisor and Clinical Supervisor will monitor compliance utilizing the monthly CQI process.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based upon a review of client records, the facility failed to document a treatment plan update every 60 days.
The findings include:
Five client records requiring documentation of treatment plan updates were reviewed on May 23, 2012. Three out of five client records did not have documentation of a treatment plan update, specifically #'s 4, 5, and 10.
Client #4 was admitted to treatment on November 19, 2011. The comprehensive treatment plan was documented on December 8, 2011 and was due to be updated by February 6, 2012, and again on April 6, 2012. As of the date of inspection, there was no documentation of a treatment plan update for client #4.
Client #5 was admitted to treatment on January 5, 2012. The comprehensive treatment plan was documented on January 31, 2012 and was due to be updated by March 31, 2012. As of the date of inspection, there was no documentation of a treatment plan update for client #5.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. The comprehensive treatment plan was documented on July 13, 2011 and was due to be updated by September 15, 2011, and again on November 14, 2011. There were two treatment plan updates documented in client record #10, however, neither documented the client's progress on goals, and both were unsigned and undated.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
An in-service will be held by the Program Supervisor on July 20, 2012 to address timelines and steps required to complete the treatment plan update.
The Program Supervisor and Clinical Supervisor will use the client census in clinical meetings and supervisory sessions to determine the completion of treatment plan review every 60 days.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
Program Supervisor and Clinical Supervisor will monitor compliance utilizing the monthly CQI process.
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709.93(a)(5) LICENSURE Client records
709.93. 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 a review of client records, the facility failed to document progress notes for each counseling session.
The findings include:
Ten client records were reviewed for documentation of progress notes on May 23, 2012. The facility failed to document progress notes in four out of ten client records, specifically records # 1, 4, 5 and 7.
Client #1 was admitted to treatment on March 21, 2012. Record of service entries documented services that occurred on the following dates: Group counseling on 3/29/12, 4/12/12, 4/19/12, 4/26/12, 5/17/12, and individual sessions on 4/11/12, 4/18/12, 4/25/12, and 5/21/12. There were no progress notes to reflect any of the sessions documented in the record of service.
Client #4 was admitted to treatment on November 19, 2011. Record of service entries documented services that occurred on the following dates: Group counseling on 11/22/11, 11/26/11, 12/8/11, 12/15/11, 12/19/11, 12/29/11, 1/19/12, 1/26/12, 2/6/12, 2/12/12, 3/19/12, 4/19/12, and individual sessions on 2/2/12, 4/12/12, and 4/19/12. There were no progress notes to reflect any of the sessions documented in the record of service.
Client #5 was admitted to treatment on January 5, 2012. Record of service entries documented services that occurred on the following dates: Group counseling on 12/2/11, 12/14/11, and 3/31/11. There were no progress notes to reflect any of the sessions documented in the record of service.
Client #7 was admitted to treatment on December 3, 2011 and discharged on March 23, 2012. Record of service entries documented services that occurred on the following dates: Group counseling on 12/27/11, 1/3/12, 1/10/12, 1/17/12, and individual sessions on 12/13/11, 1/3/12, 1/10/12, and 1/24/12. There were no progress notes to reflect any of the sessions documented in the record of service.
The facility director and clinical supervisor confirmed the progress notes were not completed.
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Plan of Correction
The Program Supervisor will meet with the counselors, who failed to document progress notes, to develop perfomance improvement plans by July 13,2012. These plans will identify strategies to ensure the timeliness progress notes.
On June 1, 2012, the Program Supervisor reintated a tracking grid to monitor group note completion.
The Administrative staff resumed the responsibility of filing clinical documentation documentation on May 25,2012.
The Program Supervisor, Clinical Supervisor, and Adminstrative Coordinator will monitor the timeliness of the filing through the monthly CQI process.
Clinical staff will be monitored by the Program Supervisor and the Clinical Supervisor in monthly supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting.
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709.93(a)(8) LICENSURE Client records
709.93. 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 upon a review of the facility's policies and procedures and client records, the facility failed to document case consultations as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of case consultations:
"Case Consults are performed every 90 days for outpatient. Case Consults are performed more frequently whenever a client has a special problem (s). The Counselor shall meet with the Clinical Supervisor on a regular scheduled basis, i.e., weekly or bi-weekly, to discuss the overall progress or problems of each client. Documentation of the case consults shall be completed by the primary Counselor."
Seven client records requiring documentation of case consultations were reviewed on May 23, 2012. Six of seven client records, did not have documentation of a case consultation, specifically #'s 3, 4, 5, 6, 7, and 10.
Client #3 was admitted into treatment on February 15, 2012. A case consultation was due by May 15, 2012 for client #3. As of the date of inspection, there was no documentation of a case consultation for client #3.
Client #4 was admitted to treatment on November 19, 2011. A case consultation was due by February 19, 2012 and May 19, 2012 for client #4. As of the date of inspection, there was no documentation of a case consultation for client #4.
Client #5 was admitted into treatment on January 5, 2012. A case consultation was due by April 5, 2012 for client #5. As of the date of inspection, there was no documentation of a case consultation for client #5.
Client #6 was admitted into treatment on January 23, 2012. A case consultation was due by April 23, 2012 for client #6. As of the date of inspection, there was no documentation of a case consultation for client #6.
Client #7 was admitted into treatment on December 3, 2011 and discharged on March 23, 2012. A case consultation was due by March 3, 2012 for client #7. As of the date of inspection, there was no documentation of a case consultation for client #7.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. A case consultation was due by September 16, 2011 for client #10. As of the date of inspection, there was no documentation of a case consultation for client #10.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
The Program Supervisor will conduct an in-service for the clinical staff on June 29, 2012, to review the treatment management procedures specific to the case consultation timelines.
The Program Supervisor and Clinical Supervisor will use the client census in clinical meetings and supervisory sessions to determine the completion of case consultations review every 90 days.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
Program Supervisor and Clinical Supervisor will monitor compliance utilizing the monthly CQI process.
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709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document aftercare plans as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of aftercare plans:
" Aftercare:
After care planning is initiated the first week of admission. During the last two sessions of treatment, the Counselor will assist the client to identify goals and action steps for continuing recovery growth post treatment. The client's plan for support group attendance and any further treatment referrals should also be noted. The plan should be copied for the client's use and the signed original maintained in the record be legible. "
Two client records requiring documentation of an aftercare plan were reviewed on May 23, 2012. Two out of two client records did not have documentation of an aftercare plan, specifically #'s 9 and 10.
Client #9 was admitted into treatment on October 22, 2011 and discharged on January 21, 2012. An aftercare plan was due by January 21, 2012 for client #9. As of the date of inspection, there was no documentation of an aftercare plan for client #9.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. An aftercare plan was due by January 18, 2012 for client #10. As of the date of inspection, there was no documentation of an aftercare plan for client #10.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
An in-service will be held by the Program Supervisor on July 20, 2012 to address timelines and steps required to complete the aftercare plan.
The Program Supervisor and Clinical Supervisor will use the client census in clinical meetings and supervisory sessions to determine the completion of the aftercare plan.
Weekly administrative meetings are scheduled to review procedures and effectiveness of filing clinical documentation.
Clinical staff will be monitored in regular supervisory sessions by the Program Supervisor and the Clinical Supervisor to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
Program Supervisor and Clinical Supervisor will monitor compliance utilizing the monthly CQI process.
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709.93(a)(10) LICENSURE Client records
709.93. 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 upon a review of the facility's policies and procedures and client records, the facility failed to document discharge summaries as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of discharge summaries:
" Discharge Summary:
After the client's treatment exit when no additional treatment services are anticipated, the Counselor shall complete the Discharge Summary within one week from discharge. "
Four client records requiring documentation of a discharge summary were reviewed on May 23, 2012. Three out of four client records did not have documentation of a discharge summary, specifically #'s 7, 9 and 10.
Client #7 was admitted into treatment on December 3, 2011 and discharged on March 23, 2012. A discharge summary was due by March 30, 2012 for client #7. As of the date of inspection, there was no documentation of a discharge summary for client #7.
Client #9 was admitted into treatment on October 22, 2011 and discharged on January 21, 2012. A discharge summary was due by January 28, 2012 for client #9. As of the date of inspection, there was no documentation of a discharge summary for client #9.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. A discharge summary was due by January 25, 2012 for client #10. As of the date of inspection, there was no documentation of a discharge summary for client #10.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
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Plan of Correction
An in-service will be held by the Program Supervisor on July 20, 2012 to address timelines and steps required to complete the discharge summary.
The Program Supervisor and Clinical Supervisor will use the client census in clinical meetings and supervisory sessions to determine the completion of the discharge summary.
Weekly administrative meetings are scheduled to review procedures and effectiveness of filing clinical documentation.
Clinical staff will be monitored in regular supervisory sessions by the Program Supervisor and the Clinical Supervisor to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
Program Supervisor and Clinical Supervisor will monitor compliance utilizing the monthly CQI process.
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709.93(a)(11) LICENSURE Client records
709.93. 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 upon a review of the facility's policies and procedures and client records, the facility failed to document follow-up information as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of follow-ups:
" Follow Up:
Within seven (7) days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate. In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted within 30 days directly by the counselor or supervisor ' s designee... "
Four client records requiring documentation of follow-ups were reviewed on May 23, 2012. Four out of four client records did not have documentation of a follow-up, specifically #'s 7, 8, 9 and 10.
Client #7 was admitted into treatment on December 3, 2011 and discharged on March 23, 2012. No referral was made. A follow-up was due by April 23, 2012 for client #7. As of the date of inspection, there was no documentation of a follow-up for client #7.
Client #8 was admitted into treatment on January 24, 2012 and discharged on April 5, 2012. No referral was made. A follow-up was due by May 5, 2012 for client #8. As of the date of inspection, there was no documentation of a follow-up for client #8.
Client #9 was admitted into treatment on October 22, 2011 and discharged on January 21, 2012. No referral was made. A follow-up was due by February 21, 2012 for client #9. As of the date of inspection, there was no documentation of a follow-up for client #9.
Client # 10 was admitted to treatment on June 16, 2011 and discharged January 18, 2012. No referral was made. A follow-up was due by February 18, 2012 for client #10. As of the date of inspection, there was no documentation of a follow-up for client #10.
The findings were reviewed with the facility director and clinical supervisor during the exit interview.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on May 17, 2011.
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Plan of Correction
July 6, 2012,the follow-up policy and procedure will be reviewed and fully implemented by the Program Supervisor and the Clinical Supervisor.
Clinical staff assigned to complete the follow-ups will be monitored in regular supervisory sessions to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in one of four records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1's personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
The findings were reviewed with the human resources staff.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all Managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file. Individual Training Plans will be completed for all employees by January 31st, 2013 as per our policy.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form (page 6) completed by the facility director on May 23, 2012, the facility failed to ensure that the staff to client ratios remained at or below 35:1.
The findings include:
Page 6 of the Staffing Requirements Facility Summary Report form completed by the facility was reviewed on May 23, 2012. The form listed the facility director, two clinical supervisors, and seven counselors for the clinical staff.
The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of current clients on each counselor ' s caseload as of May 23, 2012, the facility exceeded the allowable maximum of 35:1.
The actual client ratio is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients for each caseload. The FTE is determined by dividing the number of hours devoted to the clients ' treatment by the facility's standard work week.
Employee #8 works a total of 40 hours a week. 40 divided by the facility work week of 40 hours equals 1 FTE. The number of current clients on employee #8 ' s caseload is 39, divided by the 1 FTE is 39. This results in a ratio of 39:1, which exceeds the maximum of 35:1.
Employee #9 works a total of 40 hours a week. 40 divided by the facility work week of 40 hours equals 1 FTE. The number of current clients on employee #9 ' s caseload is 36, divided by the 1 FTE is 36. This results in a ratio of 36:1, which exceeds the maximum of 35:1.
Employee #10 works a total of 40 hours a week. 40 divided by the facility work week of 40 hours equals 1 FTE. The number of current clients on employee #10 ' s caseload is 38, divided by the 1 FTE is 38. This results in a ratio of 38:1, which exceeds the maximum of 35:1.
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Plan of Correction
Begininng June 1, 2012, the Program Supervisor, Clinical Supervisor, and Administrative Coordinator will review an updated census on a weekly basis to check for compliancy for the 35:1 ratio. Higher caseloads have been and will continue to be shifted to counselors with fewer clients.
Client attendance will be monitored during weekly supervision sessions between the counselor and the Program Supervisor or Clinical Supervisor. The client sign-in book will be utilize to identify and discharge clients for lack of attendance.
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