INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia - New Destiny 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(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility's letters of agreement and an interview with the Administrative Coordinator, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24 hour emergency psychiatric care.
The findings include:
The letters of agreement were reviewed on June 2, 2011. The facility could not provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric coverage.
An interview with the Facility Director confirmed that facility did not have an agreement in writing for emergency medical and psychiatric coverage.
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Plan of Correction
A written agreement was made with a licensed agency for 24-hour emergency psychiatric care on June 6, 2011. The signed agreement was placed in the Referral Agreement Manual on June 7, 2011. Referral agreement will be up-dated per policy every two years. Program Director will be responsible for compliance. (Date of completion: 6/7/2011.)
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record log and a conversation with the Facility Director, the facility failed to document alternate exits had been used during monthly fire drills in the last year.
The findings include:
The fire drill record log was reviewed on June 2, 2011. The log was reviewed from the time period covering June 2010 to May 2011. For the months of January 2011, February 2011, March 2011, April 2011, and May 2011 the column which read "Exit Used" indicated "Daycare". Based on the documentation, the inspector was unable to determine if the facility alternated the use of exits during monthly fire drills.
This was confirmed with the Facility Director during a conversation held on June 2, 2011.
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Plan of Correction
Gaudenzia New Destiny shall utilize alternate exit routes during fire drills in accordance with 705.10 (6). One of three drills per month will utilize an alternate exit. House managers will instruct clients on the use of these alternate exits, demonstrating the location of the exits as well as orienting clients to the emergency exits noted on the posted floor plans. This orientation will take place on a quarterly basis in addition to the monthly drills. All staff has been educated regarding the use of alternate exits at the June 16, 2011, monthly staff meeting. Use of alternate exits will be incorporate into the fire safety training provided to all staff at hire and on a quarterly basis in staff meetings.
The Program Director is responsible for follow-up to determine all steps above have been followed. The training and orientation in the use of the alternate exits will be completed by June 30, 2011, and beginning July 1, 2011, all monthly fire drill logs will document use of these exits. (Date of completion: July 1)
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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 client records and the facility's policy and procedure manual, the facility failed to document physical examinations in accordance with the project's policies and procedures in five out of six client records.
The findings include:
On June 2, 2011 six client records were reviewed for a physical examination. The facility neglected to record the physician's impressions in the physical examination in five client records, # 1, 2, 3, 4, and 6, additionally, the physical exam was documented late in client records # 2 and 6.
The facility policy titled: PHYSICAL EXAMINATION LABORATORY STUDIES states:
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.
Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client.
Client # 1 was admitted on March 21, 2011. The physical examination was completed on January 31, 2011 but did not include documentation of the physician's overall impression of the client.
Client # 2 was admitted on March 8, 2011. The physical examination was due by March 17, 2011 but was not completed until April 19, 2011. The physical examination did not include documentation of the physician's overall impression of the client.
Client # 3 was admitted on April 11, 2011. The physical examination was completed on April 16, 2011 but did not include documentation of the physician's overall impression of the client.
Client # 4 was admitted on December 6, 2010. The physical examination was due on December 15, 2010 but was not completed until January 7, 2011. The physical examination did not include documentation of the physician's overall impression of the client.
Client # 6 was admitted on October 18, 2010. The physical examination was due by October 27, 2010 but was completed until November 1, 2011. The physical examination did not include documentation of the physician's overall impression of the client.
A conversation was held with the Facility Director on June 2, 2011 in which the lack of documentation of the physician's impressions was confirmed.
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Plan of Correction
Physical examinations must be in accordance with the project's policies. A section
"Physician's Impressions," was added to the Physical form on 6/23/2011 for the purposes of documentation of the physician's overall impression. In addition, physicals will be scheduled within 24 hours of admission and conducted within 7 days of admission except on holiday or weekend. The Case Manager will oversee compliance with review by the Program Director. This will be implemented on July 1, 2011.
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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 the review of client records, the facility's policy and procedures manual, and an interview with the Facility Director, the facility failed to document an individual treatment and rehabilitation plan in accordance with the facility's policy and procedures in two of six client records.
The findings include:
On June 2, 2011, six client records requiring treatment and rehabilitation plans were reviewed. The facility did not document an individual treatment and rehabilitation plan based on information collected in client histories within the first three days of the client's admission, as per facility policy, in client records # 3 and 4.
The facility's policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" States:
"An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social and assessment and the clients [sic] problem list. The plan will be discussed with the client and changes made upon client request as appropriate."
"The treatment plan will be signed by the Client, the Primary Counselor, the Clinical Supervisor, physician (when applicable) and placed in the client record. 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) or by the third session (outpatient).Chesapeake region requires an initial TP within 24 hours)."
Client # 3 was admitted on April 11, 2011. The treatment and rehabilitation plan was due to be completed by April 14, 2011. As of the date of inspection there was no documentation of the treatment plan.
Client # 4 was admitted on December 6, 2010 and discharged on February 17, 2011. The treatment and rehabilitation plan was completed prior to the completion of the biopsychosocial assessment. The psychosocial assessment was completed on December 9, 2010 and the treatment plan was completed on December 8, 2010.
This was confirmed during a conversation with the Facility Director on June 2, 2011.
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Plan of Correction
All Treatment Plans will be completed in accordance with facility policy. An individualized treatment and rehabilitation plan will be developed after completion of the biopsychosocial history, assessment and problem list, and within 72 hours of admission not including weekends and holidays. The program director met with the clinical staff on June 23, 2011 and reviewed this policy. Counselors will have treatment plans reviewed on a monthly basis by the program director for purposes of CQI and to ensure compliance. |
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 client records, the facility's policies and procedures, and a conversation with the Facility Director, the facility failed to document a treatment plan update in accordance with the facility's policy and procedures in two of four client records.
Findings:
Facility policy (Standard: 709.51(b)(3) Subject: Histories; Dated January 2009) states:
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 and by the second or third counseling outpatient appointment and updates every 30 days for residential and the 10th session for outpatient or 90 days (which ever comes first).
Four client records requiring treatment plan updates were reviewed on June 2, 2011. The facility did not document a treatment plan update at least every thirty days in inpatient client records # 4 and 5.
Client # 4 was admitted on December 6, 2010 and discharged on February 17, 2011. The treatment plan was documented on December 8, 2010 and updated on January 6, 2011. A treatment plan update was due to be documented by February 6, 2011, but was not included in the client's record.
Client # 5 was admitted on October 25, 2010 and discharged on January 19, 2011. The treatment plan was documented on October 27, 2010 and updated on November 25, 2010. A treatment plan update was due to be documented by December 27, 2010, but was not included in the client's record.
The missing treatment plan updates were confirmed during a discussion with the Facility Director on June 2, 2011.
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Plan of Correction
All Treatment Plans will be reviewed and updated at least every 30 days. Regulation and procedure for treatment plan updates was reviewed with clinical staff on June 23, 2011. Clinical staff is responsible for updating treatment plans as specified at least every 30 days. Program Director will review treatment plan updates monthly to ensure compliance. |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
"All clients are followed up after discharge. Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt. Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up. In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder. In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form]. Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder. .Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility's policy and procedure manual contained a second written policy titled: "FOLLOW UP INFORMATION." This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
The CQI Director at the Corporate office revised the follow-up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia website forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director.
The next staff meeting on July 14 will review the new policy which states: the first follow-up will be completed within seven (7) days of the date of referral appointment made for a client leaving treatment, the referral shall be contacted by the counselor and for clients ending treatment without a referral appoint, the client shall be contacted directly within thirty (30) days . All follow-ups will be documented and maintained in the follow-up binder. The Program Director will ensure compliance by reviewing the follow-up long binder monthly and discussing the status of follow-ups during clinical meetings.
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