INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11-12, 2010 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 and a plan of correction is due on July 30, 2010.
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Plan of Correction
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709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records and the facility's policies and procedures manual, the facility failed to document treatment plans to include long-term goals for treatment in six of fifteen client records.
Findings:
Facility policy [Standard: 709.92.a.(1,2,3) Subject: Treatment Plan Dated January 2009] stated:
Gaudenzia Outpatient will ensure treatment plans include:
1.Short and long-term goals [realistic and stated in measurable terms] for treatment as formulated by both staff and from the client ' s list of issues/problems.
2.Type and frequency of treatment/rehabilitation services i.e. individual once/week, group twice/week.
3.Proposed type of support service (medical, psychiatric, psychological, economic, legal).
4.Application of the individual goals to the Discharge criteria.
5.Client ' s comments
6.Projected date of completion of goals.
Fifteen client records were reviewed for treatment plans on May 12, 2010. Treatment plans were required to address short and long-term goals. The facility failed to document treatment plans to include long-term goals in client records # 1, 3, 5, 7, 10, and 15.
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Plan of Correction
An inservice will be held on August 27,2010 to review treatment management procedures specific to the treatment planning process. Emphasis will be placed on strenths and needs from the client's psychosocial history as well as the SNAP form that is completed at the time of admission. Program Supervisor will remind all clinical staff that short and long terms goals are client driven and need to be reflected on every treatment plan to include client comments and the projected date of completion. The type and frequency of treatment to be provided will be documented on every treatment plan as well as all additional support services needed to aid in the recovery process. All progress notes should reflect this as well. All potential discharges will be presented to Program Supervisor in clinical meeting to ensure that all goals have been met and client meets discharge criteria. Program Supervisor as well as the Program Director will monitor compliance of the policy utilizing the monthly CQI process.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly admnistrative meeting. |
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 a review of client records and facility's policies and procedures, the facility failed to document treatment plans to include proposed types of supportive services in thirteen of fifteen client records.
Findings:
Facility policy [Standard: 709.92.a.(1,2,3) Subject: Treatment Plan Dated January 2009] stated:
Gaudenzia Outpatient will ensure treatment plans include:
1.Short and long-term goals [realistic and stated in measurable terms] for treatment as formulated by both staff and from the client ' s list of issues/problems.
2.Type and frequency of treatment/rehabilitation services i.e. individual once/week, group twice/week.
3.Proposed type of support service (medical, psychiatric, psychological, economic, legal).
4.Application of the individual goals to the discharge criteria.
5.Client ' s comments
6.Projected date of completion of goals.
Fifteen client records were reviewed on May 12, 2010. Treatment plans with proposed types of support services were required in fifteen client records. The facility did not document treatment plans to include proposed types of support services in client records # 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, and 16.
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Plan of Correction
An inservice will be held on August 27,2010 to review treatment management procedures specific to the treatment planning process. Emphasis will be placed on strenths and needs from the client's psychosocial history as well as the SNAP form that is completed at the time of admission. Program Supervisor will remind all clinical staff that short and long terms goals are client driven and need to be reflected on every treatment plan to include client comments and the projected date of completion. The type and frequency of treatment to be provided will be documented on every treatment plan as well as all additional support services needed to aid in the recovery process. All progress notes should reflect this as well. All potential discharges will be presented to Program Supervisor in clinical meeting to ensure that all goals have been met and client meets discharge criteria. Program Supervisor as well as the Program Director will monitor compliance of the policy utilizing the monthly CQI process.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly admnistrative meeting.
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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 on a review of client records and the facility's policies and procedures, the facility failed to document a treatment plan update in five of eleven client records.
Findings:
Facility policy (Standard: 709.92.b Subject: Treatment Plan Dated January 2009) stated:
Gaudenzia, Inc. Outpatient, will ensure treatment and rehabilitation plans will be reviewed and updated at least every sixty days. The treatment plan update will include an assessment of the client ' s progress in relationship to stated goals. Treatment plan updates will be signed and dated by the primary counselor and clinical supervisor. The following issues will be considered:
Have problems or issues identified in the treatment plan been impacted through treatment?
Should goals be revised or restated?
Do strategies or action steps need modification?
Eleven client records requiring treatment plan updates were reviewed on May 12, 2010. The facility did not document a treatment plan update at least every sixty days in outpatient client records # 1, 5, 6, 8, and 12 .
Client #1 admission date 11/4/2009; treatment plan documented 11/4/09; treatment plan update documented 5/5/10.
Client #5 admission date 1/28/2010; treatment plan documented 01/28/2010; treatment plan update documented 04/29/2010.
Client #6 admission date 10/28/2009; treatment plan documented 10/28/2009; treatment plan update documented 2/28/2010.
Client #8 admission date 2/02/2010; treatment plan documented 2/02/2010; a treatment plan update had been documented, however, it had not been signed or dated by the clinician or the client as of the date of inspection.
Client #12 admission date 12/08/2009; discharge date 3/20/2010; treatment plan documented 12/08/2009; a treatment plan update had not been documented while this client was in treatment.
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Plan of Correction
An inservice will be held on August 27,2010 to review treatment management procedures specific to the treatment planning process. All clinical staff will be reminded that all treatment plans will be updated every 60 days and will include an assessment of the client's progress in relationship to goals. Treatment plan updates will be signed and dated by the primary counselor as well as the Program Supervisor. Progress notes will reflect whether issues and goals have been achieved or improved and if they need to be revised or maintained.
When goals are changed, all action steps will be revised.
Program Supervisor as well as the Program Director will monitor compliance of the policy utilizing the monthly CQI process.
Clinical staff will be monitored in regular 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)(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 on a review of the facility's policies and procedures and client records, the facility failed to document an aftercare plan in one of one client record.
The findings include:
The facility's policy : 709.93.9 (subject: Aftercare Plan Dated January, 2009 stated:
Thirty to sixty days prior to client completing treatment an Aftercare Plan should be completed by the Primary Counselor and the client. This plan includes the following information:
1.Future goals and objectives with time frames.
2.Services to be provided and proposed frequency of contact during
Aftercare.
3.Projected date of Aftercare Termination.
4.Criteria and person to contact for re-admission.
5.Additional supportive services.
Six discharged client records were reviewed on May 12, 2010. One record was required to include a documented aftercare plan.
Client # 16 was admitted on December 5, 2009 and discharged on March 6, 2010. An aftercare plan had not been documented in record # 16 as of the date of inspection.
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Plan of Correction
An inservice will be held on August 27,2010 to review treatment management procedures specific to Aftercare Planning. All clinical staff will be reminded that an aftercare plan should be completed 30 to 60 days prior to program completion. The plan is to include future goals and objectives with time frames, additional services to be provided and proposed frequency of contact during aftercare and the projected date of aftercare termination. Criteria and person to contact for re-admission and any needed additional support services will also be addressed.
Program Supervisor as well as the Program Director will monitor compliance of the policy utilizing the monthly UM process.
Clinical staff will be monitored in regular 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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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, an active client list, daily census report, and an interview with the clinical supervisor, the facility failed to notify the Department of a change in authorized maximum capacity.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on May 12, 2010. The summary report, signed by the facility director, indicated the facility had 236 current clients. The facility is licensed by the Division for a maximum client capacity of 190.
The facility had been previously cited for being over capacity during their follow-up inspection on January 28, 2010. Their Plan of Correction submitted for the deficient practice cited on January 28, 2010 stated the following:
"Program Supervisor will review current census beginning March 1, 2010 and discharge those clients that are not attending and/or the supervisor will begin referring clients to other providers until capacity requirements are met. Program Supervisor will monitor client census to ensure it does not exceed capacity limitations on a weekly basis."
The clinical supervisor generated an active client list on May 11, 2010. The active client list had 236 current clients.
Additionally, the facility presented a record of the daily census from January 1, 2010 to April, 30, 2010. The facility was over capacity 119 of 120 days covered by the report.
1/29/2010 the census was 207; 1/30/2010 the census was 207; 1/31/2010 the census was 207. 2/1/2010 the census was 207; 2/2/2010 the census was 207; 2/3/2010 the census was 208; 2/4/2010 the census was 211; 2/5/2010 the census was 211; 2/6/2010 the census was 210; 2/7/2010 the census was 209; 2/8/2010 the census was 208; 2/9/2010 the census was 211; 2/10/2010 the census was 210; 2/11/2010 the census was 208; 2/12/2010 the census was 208; 2/13/2010 the census was 211; 2/14/2010 the census was 211; 2/15/2010 the census was 211; 2/16/2010 the census was 208; 2/17/2010 the census was 212; 2/18/2010 the census was 216; 2/19/2010 the census was 214; 2/20/2010 the census was 216; 2/21/2010 the census was 215; 2/22/2010 the census was 213; 2/23/2010 the census was 214; 2/24/2010 the census was 215; 2/25/2010 the census was 213; 2/26/2010 the census was 213; 2/27/2010 the census was 214; 2/8/2010 the census was 215;
3/1/2010 the census was 213; 3/2/2010 the census was 216; 3/3/2010 the census was 216; 3/4/2010 the census was 213; 3/5/2010 the census was 206; 3/6/2010 the census was 206; 3/7/2010 the census was 205; 3/8/2010 the census was 205; 3/9/2010 the census was 202; 3/10/2010 the census was 201; 3/11/2010 the census was 200; 3/12/2010 the census was 199; 3/13/2010 the census was 200; 3/14/2010 the census was 200; 3/15/2010 the census was 199; 3/16/2010 the census was 202; 3/17/2010 the census was 205; 3/18/2010 the census was 207; 3/19/2010 the census was 203; 3/20/2010 the census was 202; 3/21/2010 the census was 202; 3/22/2010 the census was 199; 3/23/2010 the census was 199; 3/24/2010 the census was 200; 3/25/2010 the census was 200; 3/27/2010 the census was 194; 3/28/2010 the census was 194; 3/29/2010 the census was 198; 3/30/2010 the census was 199; 3/312010 the census was 199
4/1/2010 the census was 197; 4/2/2010 the census was 200; 4/3/2010 the census was 201; 4/4/2010 the census was 201; 4/5/2010 the census was 202; 4/6/2010 the census was 207; 4/7/2010 the census was 212; 4/8/2010 the census was 213; 4/9/2010 the census was 214; 4/10/2010 the census was 216; 4/11/2010 the census was 215; 4/12/2010 the census was 217; 4/13/2010 the census was 220; 4/14/2010 the census was 219; 4/15/2010 the census was 218; 4/16/2010 the census was 215; 4/17/2010 the census was 215; 4/18/2010 the census was 215; 4/19/2010 the census was 215; 4/20/2010 the census was 216; 4/21/2010 the census was 216; 4/17/2010 the census was 216; 4/18/2010 the census was 215; 4/19/2010 the census was 215; 4/20/2010 the census was 216; 4/21/2010 the census was 216; 4/22/2010 the census was 216; 4/23/2010 the census was 215; 4/24/2010 the census was 215; 4/25/2010 the census was 215; 4/26/2010 the census was 213; 4/27/2010 the census was 216; 4/28/2010 the census was 217; 4/29/2010 the census was 218; 4/30/2010 the census was 219;
An interview was conducted with the clinical supervisor on May 11, 2010. The clinical supervisor did acknowledge that the facility was currently over the authorized client capacity. The supervisor also admitted that the client capacity had not been monitored to ensure it remained at or under 190 clients as authorized by the Department and as they had stated they would do in their Plan of Correction to the January 28, 2010 inspection.
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Plan of Correction
Effective June 24, 2010 all potential admissions were halted per Program Director. Potential clients were offered alternate referral sources or if declined were given the opportunity to be added to a waiting list per Gaudenzia's policy. All SCA's and referral sources were notified of full capacity and are updated on a weekly basis.
A previous letter was submitted by Gaudenzia's Regional Director to increase the capacity from 190 to 250 clients. Another letter will be submitted to the Division of Drug and Alcohol Program Licensurefrom Gaudenzia's Harrisburg Outpatient Program Director by August 6, 2010 requesting this increase.
Program Director and Program Supervisor review an updated census on a weekly basis to check for compliancy. Higher caseloads have been shifted to counselors with fewer clients as well as an additional full time counselor has been hired beginning August 16, 2010. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel training records, facility policies and procedures and an interview with the facility director, the facility failed to provide documentation of TB/STD and HIV/AIDS training in four of nine personnel training records as per facility policies and procedures.
The findings include:
Facility policy titled, Standard: 704.11.c Subject: General Training dated January, 2009 stated:
Core staff training shall be completed within the first three months of employment and include, but not be limited to:
DOC - Orientation - first 40 hours as per American Corrections Association standards
HIV/AIDS - 6 hours for counselors orientation period
TB/STDS - 4 hours for counselors within three months of employment and other staff within two years
Fire Safety - [do a preliminary review the first week]
CPR - orientation period
Nine personnel training records were reviewed on May 5, 2010. Nine personnel training records were required to have documentation of TB/STD and HIV/AIDS training per facility policy. The facility did not provide documentation of TB/STD and HIV/AIDS training in personnel training records for counselor # 4 and counselor assistants # 6, 8, & 9.
Employee # 4 was hired prior to the facility's January, 2009 policy; however, employee #4 is a counselor and was hired on October 22, 2008. TB/STD and HIV/AIDS training was due to be completed no later than October 22, 2009. As of the date of inspection the facility did not provide documentation of TB/STD and HIV/AIDS training for employee #4.
Employees # 6, 8, & 9, all counselor assistants, were all hired after January, 2009 and were required to have the training within three months of employment.
Employee #6 was hired 1/19/2010. There was no documentation that employee #6 completed the HIV/AIDS and TB/STD training as of May 12, 2010.
Employee #8 was hired 8/17/2009. There was no documentation that employee #8 completed the TB/STD training as of May 12, 2010.
Employee #9 was hired 12/21/2009. There was no documentation that employee #9 completed the HIV/AIDS and TB/STD training as of May 12, 2010.
An interview with the facility director on May 12, 2010 confirmed that employee #4 did not have documentation of TB/STD and HIV/AIDS training.
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Plan of Correction
A review of counselor # 4 and counselor assistant # 6, 8 & 9 personnel training records will be done by the Program Supervisor as of August 27, 2010. Any staff who has failed to attend TB/STD and HIV/AIDS training by this date will be immediately enrolled to attend the first offered training. Program Supervisor will report findings to Program Director.
New hires will have a training plan developed by staff's immediate supevisor within the first week of hire date to include DOC orientation, HIV/AIDS, TB/STD, fire safety, and CPR/FIRST AID.
Training compliancy will be added to the weekly administrative meeting agenda. |
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 completed by the facility on May 12, 2010 and an interview with the facility director and clinical supervisor, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
On May 12, 2010, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the facility director, clinical supervisor, five counselors and four counselor assistants for the clinical staff; however, the facility only documented five counselors, employees # 4, 5, 7, 10 & 11 and one counselor assistant, employee # 12, as having clients on a caseload.
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 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 clients assigned to the following employees on May 12, 2010, employees # 4, 5, 7, 10 & 11 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients ' treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 4 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 4 had 41 active clients on May 12, 2010.
Employee # 4 (40/40 = 1 FTE 41 clients/1 FTE = 41:1 caseload)
The number of hours per week devoted by Employee # 5 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 5 had 44 active clients on May 12, 2010.
Employee # 5 (40/40 = 1 FTE 44 clients/1 FTE = 44:1 caseload)
The number of hours per week devoted by Employee # 7 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 7 had 40 active clients on May 12, 2010.
Employee # 7 (40/40 = 1 FTE 40 clients/1 FTE = 40:1 caseload)
The number of hours per week devoted by Employee # 10 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 10 had 53 active clients on May 12, 2010.
Employee # 10 (40/40 = 1 FTE 53 clients/1 FTE = 53:1 caseload)
The number of hours per week devoted by Employee # 11 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 11 had 46 active clients on May 12, 2010.
Employee # 11 (40/40 = 1 FTE 46 clients/1 FTE = 46:1 caseload)
During an interview, the facility director and clinical supervisor confirmed that they had exceeded the allowable maximum caseload of 35:1 for each of the counselors, employees # 4, 5, 7, 10 & 11 above.
Additionally the facility was cited at standard 709.14(b)(5) for being over their licensed capacity which relates directly to their exceeding the maximum caseload. The Staffing Requirements Facility Summary Report reviewed on May 12, 2010, signed by the facility director, indicated the facility had 236 current clients. The facility is licensed by the Division for a maximum client capacity of 190.
See Tag A - A029, 28 Pa. Code s. 709.14 (b)(5)
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Plan of Correction
Effective June 24, 2010 all potential admissions were halted per Program Director. Potential clients were offered alternate referral sources or if declined were given the opportunity to be added to a waiting list per Gaudenzia's policy. All SCA's and referral sources were notified of full capacity and are updated on a weekly basis.
A previous letter was submitted by Gaudenzia's Regional Director to increase the capacity from 190 to 250 clients. Another letter will be submitted to the Division of Drug and Alcohol Program Licensure from Gaudenzia's Harrisburg Outpatient Program Director by August 6, 2010 requesting this increase.
Program Director and Program Supervisor 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 as well as an additional full time counselor has been hired beginning August 16, 2010.
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