INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15-16, 1009 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 and a plan of correction is due on July 21, 2009.
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Plan of Correction
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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 eight personnel records, five required documentation of mandatory HIV/AIDS and TB/SD training. The facility failed to document a minimum of six hours of HIV/AIDS training or four hours of tuberculosis training in two of five personnel records.
Findings:
Eight personnel records were reviewed on June 15-16, 2009. Six hours of HIV/AIDS training and four hours of tuberculosis training was required in five personnel records. Two records reviewed were for counselors, both requiring documentation of HIV/AIDS and tuberculosis training within the first year of employment. The facility did not document HIV/AIDS or tuberculosis training in personnel records # 5 and 7.
Personnel record #5 hire date was 9/18/06, but six hours of HIV/AIDS training was not documented at time of inspection.
Personnel record #7 hire date was 1/28/08, but four hours of tuberculosis training was not documented at the time of inspection.
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Plan of Correction
The counselor is scheduled for the next available HIV/AIDS training on 10/20/09 at Temple University. The Program Supervisor is responsible for ensuring the scheduling and attendance of required trainings by staff. The Program Supervisor will meet with the counselor upon completion of the scheduled training and review training material.
The counselor has completed 6 hours of training in HIV/AIDS dated 5/19/09 and 6 hours of training in TB/STD dated 6/29/09. Training certificates are located in Personnel record #7 and the Program Director's office.
The Gaudenzia Corporate office training institute staff will schedule all required trainings related to the first year of employment during orientation. Corporate staff will communicate to the Program Supervisor and Program Director the dates for scheduled training of all new employees.
The Program Director and Administrative Assistant will maintain responsibility for ensuring future compliance.
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a tour of the facility ' s physical plant, the facility failed to secure all client records within locked storage containers.
Findings:
A physical plant tour was conducted on June 16, 2009 at approximately 12:00. Discharged client records were stored in boxes in an occupied office.
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Plan of Correction
On 6/22/09 the Program Director ordered a locked filing cabinet to be placed in the Program Directors office. Closed files will be stored in the locked cabinet within the locked Program Directors office. The Program Director and Program Supervisor will maintain the key for the locked filing cabinet. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of 10 client records, seven records were reviewed for consents to release information. The facility failed to document informed and voluntary consent from the client for the disclosure of information contained in seven of seven client records.
Findings:
Ten client records were reviewed on June 15-16, 2009. Documentation of informed and voluntary consent was reviewed in seven records. The facility did not document informed and voluntary consent for the release of information in client records # 1, 2, 3, 4, 5, 6 and 7.
Client records # 1, 2, 3 and 4 documented the release of " client issues/problems " to insurance companies, and probation and/or parole officers. This information exceeds the limitations of 4 Pa Code 255.5.
Client records # 5, 6 and 7 did not document the client ' s right to verbally revoke signed consents for the release of information. The facility documented the client must revoke consents in writing.
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Plan of Correction
During a staff meeting scheduled for July 20, 2009 the Program Director will review the requirements for an acceptable informed consent for the release of client records to include a review of the five specific areas included in the release of information. Each staff member attending the staff meeting will sign a document indicating their understanding of the requirements.
During a staff meeting scheduled for July 20, 2009 the Program Director will distribute the Revised Gaudenzia, Inc. Confidential Request For Information and the Revised Gaudenzia, Inc. Confidential Request to Release Information (Rev7.06). This document specifically addresses the issue pertaining to the client understanding that they may revoke the consent "at any time verbally or in writing" . . .
During Continuous Quality Improvement audits of the client files the Program Supervisor will review and ensure that the appropriate signed consents to obtain and/or release confidential information are maintained in the client file. |
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 10 client records, with seven records being reviewed for psychosocial evaluations, the facility failed to document a psychosocial evaluation in five of seven client records within 72 hours of admission as per facility policy.
Findings:
Ten client records were reviewed on June 15-16, 2009. Psychosocial evaluations were reviewed in seven client records. The facility did not document a psychosocial evaluation within 72 hours after admission, as stated in the project ' s policy manual, in client records # 1, 4, 5, 6 and 7.
Client record # 1 admission date 3/27/09, but psychosocial evaluation dated 4/5/09.
Client record # 4 admission date 1/15/09, but psychosocial evaluation dated 1/21/09.
Client record # 5 admission date 2/17/09, but psychosocial evaluation dated 2/21/09.
Client record # 6 admission date 1/29/09, but psychosocial evaluation dated 2/2/09.
Client record # 7 admission date 2/19/09, but psychosocial evaluation dated 2/24/09.
Additionally:
Client records # 1, 4, 5, 6 and 7 did not document a psychosocial evaluation to include the client ' s coping mechanisms.
Client records # 6 and 7 did not document a psychosocial evaluation to include the client ' s assets, strengths or other factors the can contribute to the resolution of identified problems.
Client records # 5 and 6 did not document a psychosocial evaluation to include the client ' s potential or available support systems.
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Plan of Correction
During the staff meeting scheduled for August 17, 2009 the Program Supervisor will meet with the clinical staff for the purpose of reviewing the requirements and providing training on the appropriate completion of Biopsychosocial Histories and Assessment.
Staff will receive guidance and supervision instructing them on the appropriate method of documentation when clients are unable to cooperate throughout the 72 hour period when Biopsychosocial Histories and Assessments are to be completed.
The Program Supervisor will ensure compliance through review of Biopsychosocials during the provision of clinical supervision and at the time of Continuous Quality Improvement audits. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 on a review 10 of client records, with seven being reviewed for individual treatment and rehabilitation plans, the facility failed to document an individual treatment and rehabilitation plan developed with the client in six of seven client records.
Findings:
Ten client records were reviewed on June 15-16, 2009. Individual treatment and rehabilitation plans were reviewed in seven client records. The facility did not document an individual treatment plan in client records # 1, 2, 3, 4, 6, and 7.
The treatment plans documented in client records # 1, 2, 3, 4, 6 and 7 were not individualized. They all contained the same goals.
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Plan of Correction
During individual and group clinical supervision the Program Supervisor will review with each counselor the requirement regarding individualization of treatment plans. Through the provision of clinical supervision as scheduled by the Program Supervisor, counselors will demonstrate the ability to reflect understanding of how to develop individualized treatment plans including goals and objectives.
Periodically throughout the year the Program Director will provide in-service training, as a part of the monthly staff meetings, where issues pertaining to the preparation of treatment plans will be addressed.
All supervision provided by the Program Supervisor pertaining to the issues associated with the development of client individualized treatment plans will be recorded in the employee personnel file. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 a review of 10 client records, with seven being reviewed for type and frequency of treatment, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in seven of seven client records.
Findings:
Ten client records were reviewed on June 15-16, 2009. Treatment plans were reviewed in seven client records. The facility did not document a treatment plan to include type and frequency of treatment and rehabilitation services in client records 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
During the site visit the Program Director and Program Supervisors were provided clarification regarding how to appropriately include type and frequency of services on the individualized treatment plan. Information received will be provided to Program Staff during the staff meeting scheduled for 8/17/09.
The Program Supervisor will monitor or client records for continuing compliance during monthly Continuous Quality Improvement audits. |
709.52(a)(3) LICENSURE Support service type
709.52. 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 10 client records, with seven being reviewed for support services, the facility failed to document an individual treatment plan to include supportive services in four of seven client records.
Findings:
Ten client records were reviewed on June 15-16, 2009. Treatment plans were reviewed in seven client records. The facility did not document an individual treatment plan to include supportive services in client records # 1, 2, 3 and 4.
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Plan of Correction
During in-service training scheduled for 8/17/09 all Program Staff will be instructed by the Program Supervisor on how to document the provision of supportive services including 12 Step Meetings, Spiritual Activities, Legal Involvement, Family Functions etc.
The Program Supervisor will monitor compliance prior to signing off on individualized treatment plans. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of 10 client records, with seven being reviewed for treatment plan updates, the facility failed to document a treatment plan update in four of seven client records.
Findings:
Ten client records were reviewed on June 15-16, 2009. Treatment plan updates were reviewed in seven client records. The facility did not document a treatment plan update to include an assessment of the client progress in relationship to the stated goals of the comprehensive treatment plan in client records # 1, 2, 3 and 4.
Client record #1 treatment plan update documented on 5/18/09 did not include an assessment of progress.
Client record #2 treatment plan update documented on 5/23/09 did not include an assessment of progress.
Client record #3 treatment plan update documented on 5/18/09 did not include an assessment of progress.
Client record #4 treatment plan update documented on 1/17/09 did not include an assessment of progress.
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Plan of Correction
During the monthly staff meeting scheduled for 8/17/09 the Program Supervisor will provide an in-service training on how to complete the section of the individualized treatment plan related to reporting progress. A record of attendance will be maintained in the employees personnel file.
The Program Supervisor will monitor compliance at the time the individualized treatment plan is submitted for signature and at the time of Continuous Quality Improvement audits. |