INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Montgomery County 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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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document client orientation in five of seven records.
The findings include:
On May 26, 2011, seven client records requiring documentation of client orientation were reviewed, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document client orientation, as per facility policy, in client records # 1, 2, 3, 6 and 7.
The facility ' s policy titled: " POLICY AND PROCEDURE FOR CLIENT ORIENTATION " states:
" Clients will be given an orientation manual which is designed to familiarize them with program operations ... The client will be required to sign a formal document that states they have read and fully understand the information contained in the orientation manual. "
Client # 1 was admitted to the facility on 11/22/10, but the client record did not contain documentation of receiving an orientation manual.
Client # 2 was admitted to the facility on 1/3/11, but the client record did not contain documentation of receiving an orientation manual.
Client # 3 was admitted to the facility on 1/25/11, but the client record did not contain documentation of receiving an orientation manual.
Client # 6 was admitted to the facility on 10/20/10, but the client record did not contain documentation of receiving an orientation manual.
Client # 7 was admitted to the facility on 10/21/10, but the client record did not contain documentation of receiving an orientation manual.
An interview with the facility director on May 26, 2011 confirmed the findings.
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Plan of Correction
Clinical Supervisor will hold a seminar for all clinical staff to review the orientation process for new clients on 6/16/11. As of this date, all clients will be given all orientation paperwork and will sign off indicating receipt. The signed document will then be filed in the clinical chart. This procedure will be monitored by the Program Director. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services in five of seven client records.
The findings include:
On May 26, 2011, treatment plans in seven client records were reviewed for type and frequency of treatment and rehabilitation services, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1, 3, 4, 5 and 6.
In client record # 1, the treatment plan documented on 12/9/10 did not include type and frequency of treatment and rehabilitation services.
In client record # 3, the treatment plan documented on 2/8/11 did not include type and frequency of treatment and rehabilitation services.
In client record # 4, the treatment plan documented on 2/14/11, did not include type and frequency of treatment and rehabilitation services.
In client record # 5, the treatment plan documented on 3/22/11, did not include type and frequency of treatment and rehabilitation services.
In client record # 6, the treatment plan documented on 11/4/10, did not include type and frequency of treatment and rehabilitation services.
An interview with the facility director on May 26, 2011 confirmed the findings.
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Plan of Correction
On 6/23/11 the Clinical Supervisor will conduct a staff seminar on proper documentation of type and frequency on the treatment plan. Proper completion of this document will be monitored on a monthly basis by Program Director. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document treatment plans to include proposed types of supportive services in three of seven records.
The findings include:
On May 26, 2011, treatment plans in seven client records were reviewed for proposed types of support services, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document treatment plans to include proposed types of support services, as per facility policy, in client records # 1, 3 and 5.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
"An action plan, which will indicate more specifically the steps to be taken in order to accomplish the established goal. The action plan will also designate the person responsible for each step, i.e. client, counselor, Medical Director, etc. Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. The action plan will address the other support services in which the client is to participate including, but not limited to: medical, psychiatric, or psychological service, legal or economic assistance and Double Trouble and/or 12-step meeting attendance. In addition, the steps will relate to the Discharge Goals of the client."
In client record #1, the treatment plan documented on 12/9/10 did not include a proposed type of support service.
In client record #3, the treatment plan documented on 2/8/11 did not include a proposed type of support service.
In client record #5, the treatment plan documented on 3/22/11 did not include a proposed type of support service.
An interview with the facility director on May 26, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on May 7, 2009 for failing to document treatment plans to include proposed types of support services.
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Plan of Correction
On 6/23/11 the Clinical Supervisor will conduct a staff seminar on proper documentation of support services on the treatment plan. Proper completion of this document will be monitored on a monthly basis by Program Director. |
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 on a review of client records and an interview with the facility director, the facility failed to document treatment plan updates to include an assessment of the client ' s progress, as per facility policy, in five of seven records.
The findings include:
On May 26, 2011, seven client records requiring treatment plan updates were reviewed, specifically records # 1, 2, 3, 4, 5, 6 and 7. The treatment plan updates did not include an assessment of progress, as per facility policy, in client records # 1, 3, 4, 6 and 7.
The facility's policy titled " Treatment Plan Reviews " states:
" The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted. Any goal or action step additions, revisions and deletions shall also be reflected. Goal and action step changes shall also be reflected on the treatment plan. The update shall be signed by the Counselor and submitted to the Clinical Supervisor for review and signature. "
In client record # 1, the treatment plan updates documented on 2/9/11 and 4/4/11 did not include an assessment of progress.
In client record # 3, the treatment plan update documented on 4/5/11 did not include an assessment of progress.
In client record # 4, the treatment plan update documented on 4/14/11 did not include an assessment of progress.
In client record # 6, the treatment plan updates documented on 1/3/11 and 3/1/11 did not include an assessment of progress.
In client record # 7, the treatment plan updates documented on 12/28/10 and 2/24/11 did not include an assessment of progress.
An interview with the facility director on May 26, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on June 2, 2010 and May 7, 2009 for failing to document treatment plan updates as per facility policy.
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Plan of Correction
On 6/23/11 the Clinical Supervisor will conduct a staff seminar on proper documentation of an assessment of the client's progress on the treatment plan. Proper completion of this document will be monitored on a monthly basis by Program Director. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) 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 Director of CQI will amend the follow up policy for the Ambulatory Division to state that follow up will be done within 30 days, unless a client has been referred inpatient. In that case, follow up will be done within 7 days. The amended policy will be communicated by the Clinical Supervisor to GMCOP staff on 7/7/11 and will be overseen for compliance by the Program Director. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On May 26, 2011 the facility was again found to be out of compliance with the following standards:
1. 709.92(a)(3) - Treatment and Rehabilitation Services: Written documentation of proposed type of support service.
This area of noncompliance was also identified during the licensing inspection conducted on May 7, 2009.
2. 709.92(b) - Treatment and Rehabilitation Services: Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
This area of noncompliance was also identified during the licensing inspections conducted on June 2, 2010 and May 7, 2009.
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Plan of Correction
709.92 (a) (3): This is the second time for support services. The Clinical Supervisor, as stated earlier, will provide a staff seminar requiring special attention to the proper documentation of support services on treatment plans. This seminar is scheduled for 6/23/11. This will be monitored by Program Director.
709.92 (b): OP level of care requires treatment plans to be reviewed and updated every 60 days. The Clinical Supervisor will facilitate a staff seminar to review the proper timefram to review and update treatment plans. This seminar is scheduled for 6/23/11. The seminar with staff will focus on the fact that this is a repeat finding and will be monitored more closely. This will be monitored by Program Director for compliance on a monthly basis.
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