INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 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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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 three personnel 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 September 20, 2012, employee # 2's personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 2 has been the acting Regional Director since 1988 and has been the acting Facility Director since July 1, 2012. Per policy, training plans will be conducted in January of each year. The facility presented an undated training plan for employee # 2.
The findings were reviewed with the clinical supervisor.
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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 Regional Assistant to ensure that development of an Individual Training Plan for the Regional Director is a specific agenda item during the Regional Director's meeting with the Project Director during the month of December. A current, signed Individual Training Plan is presently in the Regional Director's file." Individual Training Plans will be completed for all employees by January 31st, 2013 as per our policy.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document that fire extinguisher training was provided upon employment in two of three personnel records reviewed.
The findings include:
Three personnel records were reviewed for documentation that fire extinguisher training was provided upon employment on September 20, 2012. The facility did not document that fire extinguisher training was provided upon employment in personnel record #'s 2 and 5.
Employee # 2 was hired at the facility on July 1, 2012, as of the date of inspection, there was no verification that employee #2 received fire extinguisher training.
Employee # 5 was hired on August 27, 2012, but the training certificate indicated this training occurred on September 11, 2012.
The findings were confirmed with the clinical supervisor.
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Plan of Correction
The HOP staff orientation schedule will be updated by November 2, 2012 to indicate the fire extinguisher trainning will be completed the first day of employment. The Program Supervisor, Clinical Supervisor, and Administrative Coordinator will responsible for monitoring the completion of the new hire training schedule during the weekly Administrative Meeting. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
Three personnel records were reviewed to verify that all personnel on all shifts had been trained to perform assigned tasks during emergencies on September 20, 2012. The facility failed to document the completion of emergency training upon hire in two of three personnel records reviewed, specifically #'s 2 and 5.
Employee # 2 was hired at the facility on July 1, 2012, as of the date of inspection, there was no verification that employee #2 received training for emergencies at this facility's location.
Employee # 5 was hired on August 27, 2012, but the training certificate indicated this training occurred on September 11, 2012.
The findings were reviewed with the clinical supervisor during the exit interview.
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Plan of Correction
The HOP staff orientation schedule will be updated by November 2, 2012 to indicate the Disaster/Fire Safety/ and Evacuation Plan will be reviewed with all new hires on the the first day of employment. The Program Supervisor, Clinical Supervisor, and Administrative Coordinator will responsible for monitoring the completion of the new hire training schedule during the weekly Administrative Meeting. |
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 and an interview with the clinical supervisor, 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 and again on September 20, 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.
An interview was conducted with the clinical supervisor on September 20, 2012. The inspector asked if any of the policies had been updated, and employee #3 advised they had not yet been updated as of the date of inspection.
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Plan of Correction
The relevant policies in the Gaudenzia Policy and Procedure manual have been 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 have been 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 were revised and approved on July 31st, 2012. They will be reviewed with staff by November 30th, 2012.
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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 on September 20, 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 third counseling session...."
Eight client records requiring documentation of individualized treatment plans were reviewed on September 20, 2012. Three out of eight client records documented treatment plans that were either late or undated, or not documented at all, specifically records #'s 1, 2, and 3.
Client #1 was admitted to treatment on June 4, 2012. The comprehensive treatment plan was due by August 2, 2012. As of the date of inspection, there was no documentation of a comprehensive treatment plan for client # 1.
Client #2 was admitted to treatment on July 5, 2012. There was documentation of a treatment plan in client #2 ' s record; however it was undated and unsigned by both the client and counselor.
Client #3 was admitted to treatment on July 5, 2012. There was documentation of a treatment plan in client #3 ' s record, however it was undated and unsigned by the client, nor was there any indication in the progress notes that the treatment plan had been reviewed with the client.
The findings were discussed with the clinical director during the exit interview.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on April 21, 2011, May 17, 2011 and May 23, 2012.
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Plan of Correction
Beginning November 1, 2012, the Program Supervisor and Clinical Supervisor will utilize an internal tracking system to ensure treatment plans are completed per policy. The Program Supervisor and the Clinical Supervisor will utilize this tracking system in weekly supervisory sessions with the clinicians. Clinicians who fail to meet agency standards will be placed on a Performance Improvement Plan and if needed will receive further disciplinary action.
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.
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. "
Seven client records requiring documentation of a discharge summary were reviewed on September 20, 2012. Two out of seven client records did not have documentation of a discharge summary, specifically #'s 9 and 14.
Client #9 was admitted into treatment on June 26, 2012 and discharged on August 18, 2012. A discharge summary was due by August 25, 2012 for client #9. As of the date of inspection, there was no documentation of a discharge summary for client #9.
Client #14 was admitted into treatment on March 21, 2012 and discharged on August 2, 2012. A discharge summary was due by August 9, 2012 for client #14. As of the date of inspection, there was no documentation of a discharge summary for client #14.
The findings were discussed with the clinical director during the exit interview.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on May 23, 2012.
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Plan of Correction
Beginning November 1, 2012, the Program Supervisor and Clinical Supervisor will utilize an internal tracking system to ensure discharge summaries are completed per policy. The Program Supervisor and the Clinical Supervisor will utilize this tracking system in weekly supervisory sessions with the clinicians. Clinicians who fail to meet agency standards will be placed on a Performance Improvement Plan and if needed will receive further disciplinary action. The Administrative Coordinator will monitor compliance utilizing the monthly CQI/Utilization process. |
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. 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... "
Five client records requiring documentation of follow-ups were reviewed on September 20, 2012. Four out of five client records did not have documentation of a follow-up, specifically #'s 9, 11, 13, and 14.
Client #9 was admitted into treatment on June 26, 2012 and discharged on August 10, 2012. No referral was made. A follow-up was due by September 10, 2012 for client #9. As of the date of inspection, there was no documentation of a follow-up for client #9.
Client #11 was admitted into treatment on June 26, 2012 and discharged on August 18, 2012. No referral was made. A follow-up was due by September 18, 2012 for client #11. As of the date of inspection, there was no documentation of a follow-up for client #11.
Client #13 was admitted into treatment on April 11, 2012 and discharged on August 9, 2012. No referral was made. A follow-up was due by September 19, 2012 for client #13. As of the date of inspection, there was no documentation of a follow-up for client #13.
Client #14 was admitted into treatment on March 21, 2012 and discharged on April 21, 2012. No referral was made. A follow-up was due by May 21, 2012 for client #14. As of the date of inspection, there was no documentation of a follow-up for client #14.
The findings were reviewed with the clinical supervisor during the exit interview.
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Plan of Correction
Beginning November 9, 2012, status of discharged clients will be reviewed by the Intake worker in the weekly clinical meetings. The Clinical Supervisory will meet with the Intake Work weekly to ensure all follow-up surveys are completed. This process will also be monitored in the Weekly administrative meeting. Failure to complete the follow-ups according to policy will result in discilinary action. |