INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2016 through May 25, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form in client record # 3. Additionally, a consent to release information form in client records # 4, 8, and 10 were missing required information.
#3 - It was documented in the client chart that the client's therapist made telephone contact on May 19, 2016 to the client's probation officer to discuss the client's attendance without obtaining a consent to release information form.
#4 - A consent to release information form dated January 21, 2016, did not include who the information was being disclosed to.
#8 - A consent to release information from to a government agency, dated November 18, 2015, did not include the signature of a witness. In addition, the facility failed to properly document the expiration date on six consents dated November 18, 2015 by only documenting 2016 as the expiration date.
#10- A consent to release information form to a parole officer, dated December 17, 2015, did not include the purpose of the release or the information that was to be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On Friday May 27, 2016 a staff meeting was facilitated to review the citations with clinical staff that was presented during the exit interview. Going forward the clinical staff is to ensure that all consent to release information forms are completed entirely leaving nothing blank. Program Director and Program Supervisor reviewed confidentiality policy with giving a brief discussion with clinical staff of the important of gaining consent to release client information and possible sending staff to confidentiality refresher course if needed. Program Director and Program Supervisor will monitor clinical charts with daily audits to ensure that all consent forms are available in the clinical chart before release of information being presented to outside resources and/or referrals.
Revision: Moving forward counselor will submit all new folders to Program Supervisor and/or Program Director for review after the first initial session to assure that the process is being followed according to our Ambulatory Policy. Chart will be reviewed for completion of all documentations that is done on the first session as required which includes the consent forms. During this time consent forms will be reviewed to assure that ALL information that is required for the forms are on the form including all signatures.
Active charts has been reviewed and discuss with clinical staff to assure that the deficiencies are revised in the charts that were reviewed. Charts will be audit to assure that the clinical staff has provided accurate information. Corrective action will be implemented by Program Supervisors and/or Program Director. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
The facility failed to maintain a data collection and record keeping system that allowed for the efficient retrieval of data during the annual licensing renewal inspection conducted on May 25, 2016 through May 26, 2016.
At approximately 9:30 am on May 24, 2016, the program supervisor provided a requested list of active and discharged clients to the licensing specialist. From the discharged list, the licensing specialist chose seven charts out of 15. At approximately 1:00 pm six discharged charts were given to the licensing specialist. The regional director reported to the licensing specialist that they were having trouble finding the last chart. At approximately 8:55 am on May 25, 2016, the program supervisor provided the licensing specialist with the last discharged chart.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward the Program Director and Program Supervisor will ensure that all discharge clinical charts are audit and properly stored in central location provided for charts that have been closed after services has been render to clients when completing, leaving ASA, transferred, therapeutic, and/or non-compliant. Discharge charts will be placed in storage space provided for closed clinical charts to ensure that the clinical chart is accessible when needed for review. |
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, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in client records #1 and 13. In addition, the facility failed to document the type and frequency of treatment services in client records #6 and 7.
Client #1 was admitted into treatment on October 14, 2015 and did not have a comprehensive treatment plan at the time of inspection.
Client #6-The comprehensive treatment plan, dated February 26, 2016, was missing the frequency.
Client #7-The comprehensive treatment plan, dated December 24, 2016 was missing the type and frequency.
Client #13 was admitted into treatment on June 23, 2015 and discharged January 4, 2016. A comprehensive treatment plan was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward the program Director and Clinical Supervisor will monitor closely clinical charts to ensure that counselors are following policy titled "Procedure For Individual Treatment & Rehabilitation Plan. Policy will be reviewed with counselor(s)during annual weekly staff meetings to ensure counselor will follow policies and procedure. Program Director & Clinical Supervisor will monitor charts to ensure that documentation (treatment plans) has indicated proposed frequency, supportive services and done timely according to the policy. Included but not limited to the comprehensive treatment plan(s) that are due 30 days following the preliminary plan that is done on the first initial session.
Revision: Going forward charts will be audit weekly by clinical staff (during staff meeting the counselors will bring charts and they will conduct their own audit), Program Supervisor and/or Program Director to assure that the charts have treatment plans as required from the initial session to the current date of active members. The charts will be audit to assure that the comprehensive treatment plan has ALL information needed included the frequencies, signatures and done in timeframe required. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include record of services, progress notes, and discharge summaries, in client records, #6, 9, 10, 11, 12, and 13.
Client #6 was admitted to the facility on January 27, 2016 and was still an active client at the time of inspection. The client record did not contain a record of services. In addition, only four group notes were in the clients chart dated: 1/28/2016, 2/1/2016, 3/24/2016, and 3/30/2016.
Client #9 was admitted to the facility on July 22, 2015 and discharged on March 31, 2016. The client record did not contain a record of services. The client was seen for twenty individual sessions from July 2015 to January 2016.
Client #10 was admitted to the facility on December 17, 2015 and discharged on April 29, 2016. The client record did not contain a record of services. In addition, there was only one individual progress note dated 2/4/2016 in the clients chart.
Client #11 was admitted to the facility on October 29, 2015 and discharged on May 4, 2016. The client record did not contain a record of services. The client was seen for fifteen individual sessions from October 2015 to May 2016 and twelve group sessions from November 2015 to April 2016.
Client #12 was admitted to the facility on May 5, 2015 and discharged on May 5, 2016. The client record did not contain a record of services. The client was seen for fifteen individual sessions from April 2015 to March 2016 and thirty two group sessions from August 2015 to May 2016.
Client #13 was admitted to the facility on June 23, 2015 and discharged on January 4, 2016. The client record did not contain a record of services and there was no discharge summary at the time of inspection. In addition, there were only four individual progress notes dated 6/23/2015, 8/5/2015, 8/19/2015, and 9/2/2015 in the clients chart.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff meeting was held Friday following the inspection on 5/27/16 to review the citations of clinical documentations that were found out of compliance.Going forward Program Director & Program Supervisor will ensure that all clinical charts are in compliance with agency policies and/or license regulations.Charts will be audit daily for clinical logs (group/individual), record of services, discharge and aftercare summary as required when services has been render. Program Director & Program Supervisor will ensure that supervisions with clinical staff is conducted monthly as well as discussions during weekly staff meets with ensuring that clinical charts have the require documentation from the initial session to the discharge date.
Revision: Going for the record services will be included in the clinical documentation to be put in the clinical charts at the onset of treatment. The administrators will log in clinical documentations upon submission of documentation from clinical staff. Administrators will be responsible for assure that all clinical documents are recorded on record of service. Program Director and Program Supervisor will audit clinical charts to assure that the process of completing record of services is being followed.
Revision: Client #9, 10, 11, 12 and Discharge summary has been and/or will be completed and any documentation that is needed will be put in the clinical chart included but not limited to chart deficiency documentation to assure the charts is in compliant. Chart #6 will be audit be Program Director to assure that the missing documentation has been corrected and the clinical chart is now in compliant. The record of service, missing clinical documentations such as counseling and group logs, discharge summaries and other needed clinical documents to bring the charts reviewed into compliance. Going forward charts will be audited including discharges by the Program Supervisor and Program Director to assure that all clinical documentations needed to assure charts being compliant on daily (weekly). |