INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from November 6 - 9, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC Inc., 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and administrative documentation, the facility failed to follow its own policies regarding the completion of the following staff development components:
1) an assessment of staff training needs for 2012
2) an overall plan for addressing staff training needs for 2012
3) and an annual evaluation of the overall training plan for 2011
4) individualized training plans for 2012
The findings include:
The P&P Manual and administrative documentation were reviewed from November 6 - 7, 2012. The facility failed to adhere to its own time frames in regard to 4 out of the 4 areas identified above.
The facility's Staff Development Program specifies that the following components are to be completed no later than the identified time frames:
1) an assessment of staff training needs for 2012 - due by January 31, 2012
2) an overall plan for addressing staff training needs for 2012 - due by January 31, 2012
3) and an annual evaluation of the overall training plan for 2011 - due by December 31, 2011
4) individualized training plans for 2012 - due by January 31, 2012
The following administrative document was reviewed on November 7, 2012:
"Gaudenzia DRC, Inc., Annual Assessment Of Trainings, Wednesday, June 6, 2012"
The document referenced above was signed and dated by the Division Director, as well as the Director of Human Resources, on June 6, 2012. The document included the following plans, evaluations and / or assessments:
"Staff Training Comments, Evaluation of Training Effectiveness, Program Training Needs, Training Assessment and Plan, Overall Training Plan for Up Coming Year, 2012 Training Calendar."
Since the Evaluation of Training Effectiveness (2011), Training Assessment and Plan (2012), and the 2012 Training Calendar were not completed until June 6, 2012, all three elements were late.
In addition, four employee records requiring individual training plans for 2012 were reviewed on November 7, 2012. Three of four records, specifically #'s 1, 2 and 3 contained treatment plans that were late as they were not completed by January 31, 2012.
Employee # 1 was hired on December 7, 1997. The individual training plan for 2012 was late as it was not completed until May 22, 2012.
Employee # 2 was hired on October 13, 2009. The individual training plan for 2012 was late as it was not completed until September 12, 2012.
Employee # 3 was hired on March 16, 2009. The individual training plan for 2012 was late as it was not completed until February 17, 2012.
The findings were reviewed with the Project Director during the exit interview and were not disputed.
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Plan of Correction
The Human Resource Director will develop a comprehensive staff development program for agency personnel that include an assessment of staff training needs, an overall plan for addressing these needs, a mechanism that will collect feedback on the completed trainings and an annual evaluation of the overall training plan by January 31, 2013. The individual training plans for each employee will be developed by January 31, 2013 with input from the employee and supervisor.
All training documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Human Resource and Outpatient Directors.
Persons Responsible: Human Resource Director, Outpatient Director
Timeframe for Completion: January 31, 2013 |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug and alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Administrative documentation, which included the project's annual fiscal audit, was reviewed on November 6, 2012.
As per administrative documentation, the project's fiscal year runs from July 1 to June 30. The project's annual fiscal audit for July 1, 2010 to June 30, 2011, was late as it was not completed until February 29, 2012.
The findings were reviewed with the Project Director during the exit interview and were not disputed.
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Plan of Correction
The Division Director under the supervision of the Executive Director will ensure that the agency's actual Annual Report is completed upon conclusion of the fiscal year.
Persons Responsible: Executive Director, Division Director
Timeframe for Completion: December 31, 2012 |
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 the review of client records, the facility failed to develop individualized treatment and rehabilitation plans.
The findings include:
Eight client records requiring individualized treatment plans were reviewed from November 8 - 9, 2012. Two of eight records, specifically #'s 1 and 6, contained treatment plans that were not individualized as they contained standardized goals and objectives.
Client # 1 was admitted on August 20, 2012, and was still an active client on the date of inspection. The treatment plan that was signed on September 17, 2012, was not individualized as it contained standardized treatment goals and objectives that were the same as those in record # 6.
Client # 6 was admitted on July 31, 2012, and was still an active client on the date of inspection. The treatment plan that was signed on August 14, 2012, was not individualized as it contained standardized treatment goals and objectives that were the same as those in record # 1.
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
A record-keeping training that included a review of the treatment planning systems was facilitated on November 16, 2012. The training ensured that all staff is trained to develop individualized treatment and rehabilitation plans as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.92(a).
All treatment planning documentation to include individualized treatment and rehabilitation plans will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible: Division Director of Clinical Services, OP Program Director
Timeframe for Completion: February 8, 2013
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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 upon the review of client records, the facility failed to develop individualized treatment plans to include goals and objectives related to addiction needs identified on the psychosocial assessment.
The findings include:
Eight records requiring individualized treatment plans were reviewed from November 8 - 9, 2012. Treatment plans contained in three of eight records, specifically #'s 1, 3, and 6, did not include goals and objectives related to addiction needs identified on the psychosocial assessment.
Client # 1 was admitted on August 20, 2012, and was still an active client on the date of inspection. The treatment plan that was signed on September 17, 2012, did not contain goals and objectives related to the client's addiction needs.
Client # 3 was admitted on July 16, 2012, and was still an active client on the date of inspection. The treatment plan that was signed on August 1, 2012, did not contain goals and objectives related to the client's addiction needs.
Client # 6 was admitted on July 31, 2012, and was still an active client on the date of inspection. The treatment plan that was signed on August 14, 2012, did not contain goals and objectives related to the client's addiction needs.
The findings were reviewed with the Facility Director during the exit interview and were not disputed.
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Plan of Correction
A record-keeping training to include a review of the treatment planning systems was facilitated on November 16, 2012. The training ensured that all staff is trained to develop individualized treatment and rehabilitation plans to include short and long term goals and objectives related to addiction needs identified on the psychosocial assessment as required by the Division of Drug and Alcohol Licensure per DOH Policy 709.92(a)(1).
All treatment planning documentation will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings by the Program Director and Clinical Supervisor.
Persons Responsible: Division Director of Clinical Services, OP Program Director
Timeframe for Completion: February 8, 2013
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