INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26-28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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 June 28, 2010.
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Plan of Correction
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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 on a review of client records and the program's policies and procedures, the facility either failed to document treatment plans based on the clients' biopsychosocial histories; develop them with the client; or document them at all in seven of twelve client records.
The findings include:
On May 26 & 27, 2010, thirteen outpatient client records were reviewed. Twelve of those records required documentation of a comprehensive treatment plan.
The program policy states, "The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social assessment and the clients problem list". The facility failed to reference the clients' biopsychosocial assessments and drug and alcohol histories when creating the treatment plans in three out of twelve client records; specifically records # 2, 6, and 8. This is evidenced by the comprehensive treatment plans being completed prior to the clients' histories and assessments.
Client # 2 was admitted on 2/17/2010; the client's history and biopsychosocial evaluation were completed on 2/24/2010; the treatment plan was completed on 2/17/2010.
Client # 6 was admitted on 4/30/2010; the client's history was completed on 5/18/2010; the treatment plan was completed on 4/30/2010.
Client # 8 was admitted on 3/3/2010; the client's history and biopsychosocial evaluation were completed on 11/2/2009 and 11/3/2009 respectively. However, there was no documentation that the information had been updated or reviewed with the client since admission. The treatment plan was completed on 3/31/2010.
The facility failed to develop the treatment plans with the client in two out of twelve client records; specifically records #9 and 10. This is evidenced by:
Client # 9 was admitted on 10/17/2009, the treatment plan was dated 10/17/2009; signed by the counselor on 10/17/2009 and signed by the client on 10/30/2009.
Client # 10 was admitted on 11/10/2009, the treatment plan was dated 11/10/2009; signed by the counselor on 11/10/2009 and signed by the client on 11/25/2009.
The facility's policy states that an individual treatment and rehabilitation plan will be completed within three sessions for outpatient clients. The facility failed to develop a treatment plan in two out of twelve client records; specifically records #1 and 12.
Client # 1 was admitted on 3/18/2010, the client had attended counseling sessions on 4/16; 4/20; 4/28; 4/30; 5/3; 5/10; and 5/14. As of the date of inspection, a treatment plan had not been developed for client #1.
Client # 12 was admitted on 11/25/2009 and discharged on 4/1/2010, the client had attended counseling sessions on 11/25; 12/9; 12/24; 2/3; 3/2 and 3/9. As of the date of inspection, a treatment plan had not been developed for client #12.
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Plan of Correction
Program Supervisor will hold inservice on July 2, 2010 to review treatment management procedures specific to the treatment planning process, timeliness of treatment plan completion within the initial three sessions and the inclusion of strengths/needs from the psychosocial history as well as the SNAP form completed at evaluation and/or admission.
Program Supervisor will monitor compliance of policy and the above mentioned information utilizing the program census report. The timeliness of treatment plan completion will be monitored through the monthly CQI process.
Clinical staff members will be monitored in regular supervisory sessions to include corrective action, if necessary, for failure to comply with standards. Program Director will monitor Program Supervisor's census and CQI reports on a monthly basis to assure that there is adherence for compliance. Failure to adhere to the above plan will result in corrective action. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of client records and the program's policies and procedures, the facility failed to effectively document progress notes in four out of eight outpatient client records.
The findings include:
On May 26-27, 2010 thirteen client records were reviewed. Eight of those client records required documentation of group progress notes. The program's policy states, "One group note will suffice provided that it includes a comment relative to each individual's response or participation in the group session". Furthermore the Assessment portion of the group note form specifies the counselor should document "the client's participation behavior, interaction, and self disclosure, and counselor's interpretation". The facility failed to assess the individual client in the group progress notes in four of eight client records, specifically records # 4, 9, 10, and 12.
The group progress notes in client record # 4 dated 4/21/10, 4/23/10, 4/30/10, 5/5/10, 5/7/10, and 5/12/10 did not include an assessment of the individual client.
The group progress notes in client record # 9 dated 11/10/09, 11/23/09, 11/27/09, 12/2/09, 12/4/09, 12/7/09, 12/11/09, 12/16/09, 1/22/10, 23/5/10, and 2/12/10 did not include an assessment of the individual client.
The group progress notes in client record # 10 dated 11/16/09, 11/23/09, 11/30/09, 12/7/09, 12/10/09, 12/22/09, 1/7/10, 1/28/10, and 2/4/10 did not include an assessment of the individual client.
The group progress notes in client record # 12 dated 2/23/10, 3/2/10, and 3/9/10 did not include an assessment of the individual client.
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Plan of Correction
Program Supervisor will hold inservice on July 2, 2010 to review treatment management procedures, DAP format specific to the completion of group notes.
The completion of group notes as per policy will be monitored by the Program Supervisor in the CQI process, adding the group note to the quality review process and documented in the comment section on said forms. Any portions determined to be problematic will be addressed in supervisory sessions, corrective action will be implemented, if necessary. Program Director will monitor in the CQI reports for compliance. Failure to adhere to the above plan will result in corrective action. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records the facility failed to ensure that each counselor completed at least 25 clock hours of training.
The findings include.
Eight personnel records were reviewed on May 26, 2010. Employee # 7 was hired on 10/23/2006 and accepted a counselor position on 8/26/2008. Employee # 7 had only 19 clock hours of training for the 2009 fiscal year.
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Plan of Correction
Individual training plans will be reviewed in staff meeting on July 2, 2010 regarding the number of hours met thus far this calendar year. Program Supervisor will review core trainings and the number of hours necessary for each position annually. Scheduled training will be spread out through the year for each employee. Training reports are completed by the Administrative Coordinator to list trainings attended on a monthly basis. Program Supervisor will review the scheduling process for trainings and the responsibility of each counselor to track and schedule the necessary hours of training per year. Program Director will monitor compliance through training reports and staff meeting minutes. Failure to adhere to the above plan will result in corrective action. |
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 26, 2010 and an interview with the program supervisor, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings include:
On May 27, 2010 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the facility director, program supervisor, seven counselors and one counselor assistant for the clinical staff. All but the facility director was documented as having clients on a caseload, as the facility director is not located in this office.
Seven counselors' and one counselor assistant's caseloads were reviewed on May 27, 2010. Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, five counselors exceeded the client to counselor ratio of 35:1.
Employee # 4 had a client to counselor ratio of 36:1
Employee # 6 had a client to counselor ratio of 39:1
Employee # 7 had a client to counselor ratio of 36:1
Employee # 9 had a client to counselor ratio of 36:1
Employee # 10 had a client to counselor ratio of 37:1
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Plan of Correction
Program Supervisor met with Drug and Alcohol Licensing Specialist at the wrap up of WSOP's licensing visit on May 28, 2010. The ratio formula was reviewed in regards to 35:1 and how that is calculated with the 37 1/2 hour work week. The capacity for WSOP will be monitored on a monthly basis through the Monthly Census Statistical Report completed by the Administrative Coordinator. The Program Supervisor will monitor client/staff ratio from this report to ensure 35:1 capacity. The Program Director will monitor capacity and ratio through the above report. |