INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5-6, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Together House 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The facility's fire drill logs were reviewed on June 3, 2013. The fire drill logs were reviewed from the last survey, June 2012 to May 2013. The only documented fire drill during sleeping hours was conducted on February 28, 2013.
This was discussed with and confirmed by the program director.
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Plan of Correction
A training has been scheduled and will be conducted by the Program Director and Physical Plant Specialist to address conducting fire drills and documentation of fire drill logs. This training will include frequency of fire drills to include at least one every six months during sleeping hours. Program Supervisor will be responsible for providing monthly supervisory follow up and Program Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2013 |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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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 a psychosocial evaluation in accordance with its policy or failed to include an evaluation of the client's composite picture.
The findings include:
In reference to the timelines for the completion of biopsychosocial evaluations, the facility's policy states: The biopsychosocial evaluation shall be completed within three to five treatment days after the client's admission into the residential program.
Six client records were reviewed for psychosocial evaluations on June 3-4, 2013. Five out of six client records lacked documentation of a psychosocial evaluation that was completed per facility policy, specifically client records #1, 2, 3, 4, and 5.
Client #1 was admitted to treatment on April 22, 2013. As of the date of inspection a psychosocial evaluation had not been completed for client #1.
Client #2 was admitted to treatment on March 27, 2013. A psychosocial evaluation had been completed on March 28, 2013 but did not include a composite picture of client # 2.
Client #3 was admitted to treatment on April 22, 2013. A psychosocial evaluation had been completed on April 24, 2013 but did not include a composite picture of client # 3.
Client #4 was admitted to treatment on March 12, 2013. A psychosocial evaluation had been completed on March 14, 2013 but did not include a composite picture of client # 4.
Client #5 was admitted to treatment on March 12, 2013. A psychosocial evaluation had been completed for client #5 but was unsigned and undated, and did not include a composite picture or an assessment of the client's of problems and/or needs.
The findings were reviewed with the program director and clinical supervisor.
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Plan of Correction
A training has been scheduled and will be conducted by the Program Director and Program Supervisor to address documentation. This training will include completion of biopsychosocial evaluations to include an evaluation of the client's composite picture. Program Supervisor will be responsible for providing monthly supervisory follow up and Program Director will be responsile for ongoing oversight. Full compliance will be met efective July 31, 2013. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plans.
The findings include:
Six client records were reviewed for the provision of clinical services on June 5, 2013. Services and treatments are to be provided according to the recommendations in the individual treatment and rehabilitation plan. The facility did not document services according to the individual treatment plan in five out of six client records, specifically # ' s 1, 2, 3, 5, and 6.
Client # 1 was admitted on April 22, 2013. The individual treatment and rehabilitation plan was completed on April 26, 2013. This treatment plan stated the client was to receive an individual counseling session once a week and group sessions four times a week. The last documented individual treatment session for client #1 was dated 5/21/13. Furthermore, there was not one documented group session in the client ' s record.
Client # 2 was admitted on March 27, 2013. The individual treatment and rehabilitation plan was completed on March 29, 2013. This treatment plan stated the client was to receive an individual counseling session once a week and group sessions three times a week. The last documented individual treatment session for client #1 was dated 5/23/13 and the last group session was documented on 5/1/13.
Client # 3 was admitted on April 22, 2013. The individual treatment and rehabilitation plan was completed on April 23, 2013. This treatment plan stated the client was to receive an individual counseling session once a week and group sessions five times a week. The only documented group treatment sessions for client # 3 were dated 5/1/13 and 5/24/13.
Client # 5 was admitted on March 12, 2013 and discharged on April 1, 2013. The individual treatment and rehabilitation plan was completed on March 15, 2013. This treatment plan stated the client was to receive an individual counseling session once a week and group sessions five times a week. The only documented individual treatment session for client # 5 was dated 3/12/13. The only documented group notes for client # 5 were dated 3/11/13, 3/14/13, and 4/1/13.
Client # 6 was admitted on February 1, 2013 and discharged on April 1, 2013. The individual treatment and rehabilitation plan was completed on February 4, 2013. This treatment plan stated the client was to receive an individual counseling session once a week and group sessions five times a week. The only documented individual treatment session for client # 6 was dated 2/1/13. Furthermore, the last documented group note for client # 6 was dated 3/18/13.
The findings were confirmed with the program supervisors.
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Plan of Correction
A training has been scheduled and will be conducted by the Program Director and rogram Supervisor to address documentation. This training will include assuring that counseling services are provided according to the individual treatment and rehabilitation plans. Program Supervisor will be responsible for providing monthly supervisory follow up and Program Director will be responsible for oversight. Full compliance will be met effective July 31, 2013. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete chronological listing of the various specific services provided to each individual.
The findings include:
Six inpatient records were reviewed for documentation of a record of service on June 5, 2013. The facility failed to document services as provided to the clients in four out of six client records, specifically #'s 1, 2, 4, 5 and 6.
Client #1 was admitted into treatment on April 22, 2013 and was still active during the inspection. There was no record of services for treatment that occurred during May 2013 for client #1. Furthermore, the record of services documented for April 2013 does not specify the day the service was provided, it only specifies the week during which the service occurred.
Client #2 was admitted to treatment on March 27, 2013. Progress notes for individual session dated: 3/29/13, 4/5/13, 4/11/13, 4/25/13, 5/2/13, 5/16/13, and 5/23/13 were documented in the client's record; however they were not reflected in the record of services for client #2.
Client #4 was admitted to treatment on March 12, 2013 and discharged on April 30, 2013. Progress notes for group sessions dated 4/24/13, 4/26/13, and 4/29/13 and an individual session held on 3/15/13 were documented in the client's record, however it was not reflected in the record of services for client #4.
There was no documentation of a record of service in the chart representing client #5.
There was no documentation of a record of service in the chart representing client #6.
The findings were discussed with the program supervisors prior to the exit interview.
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Plan of Correction
A training has been scheduled and will be conducted by the Program Director and Program Supervisor to address documentation. This training will include records of service which document a complete chronological listing of the various specific services provided to each individual. Records of service for clients # 1 and 2 were updated to accurately reflect services rendered on 6/7/2013. Program Supervisor will be responsible for monthly supervisory follow up and Program Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2013. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
Six client records were reviewed for documentation of progress notes on June 5, 2013. The facility failed to document progress notes in three of six client records, specifically records # 1, 2, and 4.
Client #1 was admitted to treatment on April 22, 2013. The record of services documented for client #1 does not specify the day the service was provided, it only specifies the week during which the service occurred. The record of service entries documented eight group counseling sessions conducted during the week of 4/21/13 and eight group counseling sessions which occurred during the week of 4/28/13. There were no progress notes to reflect any of the aforementioned sessions documented in the record of service.
Client # 2 was admitted to treatment on March 27, 2013. Record of service entries documented services that occurred on the following dates: Group counseling on 5/2/13, 5/6/13, 5/7/13, 5/8/13, 5/9/13, 5/10/13, 5/13/13, 5/15/13, 5/16/13, 5/17/13, 5/20/13, and 5/21/13. There were no progress notes to reflect any of the aforementioned sessions documented in the record of service.
Client #4 was admitted to treatment on March 12, 2013. Record of service entries documented services that occurred on the following dates: Group counseling on 3/14/13, 3/15/13, 3/19/13, 3/21/13, 3/25/13, 3/26/13, 3/27/13, 4/1/13, 4/2/13, 4/3/13, 4/4/13, 4/5/13, 4/8/13, 4/9/13, 4/10/13, 4/11/13, 4/12/13, 4/15/13, 4/16/13, 4/17/13, 4/18/13, and 4/22/13. There were no progress notes to reflect any of the aforementioned sessions documented in the record of service.
The findings were discussed with the program director and program supervisors.
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Plan of Correction
A training has been scheduled and will be conducted by the Program Director and Program Supervisor to address documentation. This training will include progress notes to document each counseling session. The records for clients # 1, 2, and 4 are all in the process of being updated and will be complete by July 31, 2013. Program Supervisor will be responsible for providing monthly supervisory follow up and Program Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2013. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 6-8, 2013.
In reference for the time line for follow-ups the facility's policy states:
Within seven days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor. 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.
Three client records requiring documentation of follow-ups were reviewed on June 5, 2013. Three out of three client records did not have documentation of a follow-up, specifically # 4, 5, and 6.
Client # 4 was discharged on March 12, 2013. As of the date of inspection, there was no documentation of a follow-up for client # 4.
Client # 5 was discharged on April 1, 2013. As of the date of inspection, there was no documentation of a follow-up for client # 5.
Client # 6 was discharged on April 1, 2013. As of the date of inspection, there was no documentation of a follow-up for client #6.
The findings were reviewed with the program supervisors prior to the exit interview.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will include documentation of follow up per our policy. A follow up was completed on client #'s 4, 5, and 6. These follow up were conducted on June 10th, 2013. Program Supervisor will be responsible for providing supervisory follow up and Program Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2013. |