INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7-8, 2010 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 August 31, 2010.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records and an interview with the clinical supervisor, the facility failed to document the qualifications for the position of counselor in one of four personnel records.
The findings include:
Ten personnel records were reviewed on June 7-8, 2010. Of the ten records reviewed, four were identified as counselors, but the qualifications for the position of counselor were not included in personnel record #7.
Personnel record #7 contained college transcripts, but the transcripts did not indicate if a degree was awarded in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field.
An interview with the clinical supervisor was conducted on June 8, 2010. The clinical supervisor confirmed that personnel record #7 did not contain verification of the qualifications for the position of counselor.
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Plan of Correction
To ensure necessary documentation of employee qualifications are provided the following steps will be followed. Program Director will ensure that necessary documentation of qualifications is placed in the employee hire packet at the time of hire. In addition to this information going into the personnel file at the facility, a copy is also required to be sent to the corporate office prior to first day of employment. The administrative coordinator will conduct supervisory follow up by contacting the corporate office to confirm each new hire packet has been received with the proper contents. In addition the program director will be responsible for oversight and conduct random audits of personnel files on a monthly basis to ensure completeness of personnel records at both the facility and the corporate office. Full compliance will be met effective 09/03/2010. Personnel record # 7 has been reviewed and the required documentation of qualifications are in place. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of clinical supervision notes and an interview with the clinical supervisor, the facility failed to document direct observation supervision for counselor assistants.
The findings include:
Supervision notes were reviewed and an interview with the clinical supervisor was conducted on June 8, 2009. One employee was identified as a counselor assistant and required direct observation supervision. The facility did not document direct observation for personnel #9.
Personnel #9 was hired on 4/12/08 as a high school level counselor assistant with no previous clinical experience.
Personnel #9 was required to counsel clients only under the of direct observation of a trained counselor or clinical supervisor for the first three months of employment.
The documented supervision notes for personnel # 9 did not indicate if direct observation was occurring.
The client census forms provided by the clinical supervisor stated personnel #9 had a caseload of 5 clients.
The clinical supervisor confirmed that direct observation for personnel #9 had not occurred.
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Plan of Correction
Program Director will meet with clinical supervisor to review and train on the standards for supervision of all counselor assistants. This will include supervision, direct observation, and the documentation requirements. Clinical supervisor will supervise and document supervison according to standard for personnel file #9 for a period of nine months from the date of this submitted POC before consideration of completed supervision period. Program Director will be responsible for supervisory follow up and Division Director will be responsible for oversight.
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the personnel training records, facility policies and procedures and an interview with the Training Manager, the facility failed to document feedback on completed training in four of five records.
The findings include:
Five personnel training records were reviewed on May 7, 2010 for documentation of training completed in 2009, and required documentation of feedback on the completed training. The facility lacked documented feedback on the completed training in records # 3, 4, 5 and 6.
The facility ' s policy titled " PLAN FOR COLLECTION OF FEEDBACK ON STAFF TRAINING " states:
" Each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/ Clinical Supervisor. "
An interview with the Training Manager on May 7, 2010 confirmed that personnel training records #3, 4, 5 and 6 did not contain Staff Training Reports.
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Plan of Correction
Clinical supervisor will conduct a training on the process and policy for completing training feedback forms. The administrative coordinator will provide supervisory follow up by collecting feedback forms the day after a training is held. In addition to this they will fax a copy to the corporate office. The program director will be responsible for oversight and conduct random audits of personnel files on a monthly basis to ensure completeness of personnel records at both the facility and the corporate office. Full compliance will be met effective 09/03/2010.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel training records, the facility failed to document an individual training plan in six of six records.
The findings include:
Six personnel training records were reviewed on May 7, 2010 for individual training plans. The facility did not document a training plan by January 1, as per facility policy, in personnel records # 1, 2, 3, 4, 5 and 6.
Gaudenzia, Inc. Personnel Manual policy titled " 4030 Staff Training " states:
" Prior to January of each year, employees will be given an individual training plan by their supervisor. Employees are required to complete this form before January 1, and submit the completed form to the Program Director. "
The individual training plan in personnel training record #1 was documented on 4/28/10.
Employee #2 was hired on 6/11/2001 there was no individual training plan in the personnel record at the time of the review on May 7, 2010.
Employee #3 was hired on 12/13/1999 there was no individual training plan in the personnel record at the time of the review on May 7, 2010.
Employee #4 was hired on 6/11/2000 there was no individual training plan in the personnel record at the time of the review on May 7, 2010.
Employee #5 was hired on 1/28/2008 there was no individual training plan in the personnel record at the time of the review on May 7, 2010.
Employee #6 was hired on 8/26/2007 there was no individual training plan in the personnel record at the time of the review on May 7, 2010.
# 2, 3, 4, 5 and 6 did not contain an individual training plan at the time of review on May 7, 2010.
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Plan of Correction
To ensure individual training plans are completed on each employee the division director will conduct a training on the process and policy for completing individual training plans. The clinical supervisor will be responsible for completing and reviewing with the employee an individual training plan by the required time. The administrative coordinator will be responsible for supervisory follow up by auditing personnel files monthly. The program director will be responsible for oversight and conduct random audits of personnel files. Individual training plans have been completed on file #'s 2,3,4,5 and 6. Full compliance will be met effective 09/03/2010.
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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 personnel training records, facility policies and procedures and an interview with the Training Manager, the facility failed to provide documentation of HIV/AIDS and/or TB/STD training in four of five records as per facility policies and procedures.
The findings include:
Facility policy titled, Standard: 704.11.c Subject: General Training dated January, 2009 stated:
Core staff training shall be completed and include, but not be limited to:
HIV/AIDS
TB/STDS
Fire Safety
CPR First Aid - as per staff identified for each facility
Confidentiality - in Pennsylvania must be BDAP approved with a BDAP approved trainer
Therapeutic Community Principles
Ethics
Cultural Diversity
Management of Escalation/Work Force Violence
Suicide assessment/management
Age Specific Trainings
Memorandum 46 - State of Delaware
Additional for Case Managers - PCPC2 and/or ADAM (adolescent level)
Screening and Assessment
Six personnel training records were reviewed on May 7, 2010. Of the six records reviewed, five were required to have documentation of HIV/AIDS and TB/STD training per facility policy. The facility did not provide documentation of HIV/AIDS and/or TB/STD training in records # 3, 4, 5 and 6.
Employee #3 is a clinical supervisor and was hired on December 13, 1999. TB/STD training was due to be completed no later than December 13, 2001. As of the date of inspection, the facility did not provide documentation of TB/STD training for employee #3.
Employee #4 is a clinical supervisor and was hired on June 11, 2000. HIV/AIDS and TB/STD training was due to be completed no later than June 11, 2002. As of the date of inspection, the facility did not provide documentation of HIV/AIDS and TB/STD training for employee #4.
Employee #5 is a counselor and was hired on January 28, 2008. HIV/AIDS and TB/STD training was due to be completed no later than January 28, 2009. As of the date of inspection, the facility did not provide documentation of HIV/AIDS and TB/STD training for employee #5.
Employee #6 is a counselor and was hired on August 26, 2007. TB/STD training was due to be completed no later than August 26, 2008. As of the date of inspection, the facility did not provide documentation of TB/STD training for employee #6.
An interview with the training Manager was conducted on May 7, 2010. The Training Manager confirmed that the training records for employees # 3, 4, 5 and 6 did not have documentation of HIV/AIDS and/or TB/STD training.
This deficiency was cited previously on 6/16/09. Employee #5 was among those cited during the 6/19/09 inspection.
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Plan of Correction
Program director will conduct a training on the process and policy for completing mandatory communicable training. In addition the entire agency has instituted a process so that newly hired employees will be assigned dates for these required trainings within the required time of their employment. Administrative coordinator will be responsible for supervisory follow up by conducting monthly audits of all personnel files. If it is discovered a required training has been missed or cancelled they will notify the program director so another training can be scheduled. Program director will be responsible for oversight and conduct random audits of personnel files to ensure completeness at the facility and the corporate office. Required trainings are documented and filed in personnel files # 3, 4,and 5. Employee # 6 is no longer with the agency. Full compliance will be met effective 09/03/2010. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel training records and an interview with the Training Manager, the facility failed to document at least 12 clock hours of training annually for each clinical supervisor in two of two records.
The findings include:
Two personnel training records for clinical supervisors were reviewed on May 7, 2010 to ensure that each had completed 12 hours of training for the 2009 training year. The facility did not document at least 12 hours of training for personnel # 3 and 4.
The training record for personnel #3 contained 0 hours of training for the 2009 training year.
The training record for personnel #4 contained 9 hours of training for the 2009 training year.
An interview with the training Manager was conducted on May 7, 2010. The Training Manager confirmed that the training records for personnel # 3 and 4 did not contain at least 12 hours of training for the 2009 training year.
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Plan of Correction
Program director will conduct a training on the requirements for annual training of a clinical supervisor with appropriate staff. Administrative coordinator will be responsible for supervisory follow up by conducting monthly audits of all personnel files for required training documentation. Program director will be responsible for oversight and conducting random audits of personnel files to ensure completeness at the facility and the corporate office. Required trainings are documented and filed for personnel file # 3. Trainings for personnel file # 4 have been scheduled. Full compliance will be met effective 09/17/2010. |
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 the review of personnel training records and an interview with the Training Manager, the facility failed to document at least 25 clock hours of training annually for each counselor in two of two records.
The findings include:
Two personnel training records for counselors were reviewed on May 7, 2010 to ensure that each had completed 25 hours of training for the 2009 training year. The facility did not document at least 25 hours of training for personnel # 5 and 6.
The training record for personnel #5 contained 6 hours of training for the 2009 training year.
The training record for personnel #6 contained 6 hours of training for the 2009 training year.
An interview with the training Manager was conducted on May 7, 2010. The Training Manager confirmed that only 6 hours of training had been documented for personnel # 5 and 6.
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Plan of Correction
Program director will conduct a training on training requirements for a counselor with appropriate staff. Administrative coordinator will be responsible for supervisory follow by conducting monthly audits of all personnel files for required training documentation. Program director will be responsible for oversight and conducting random audits of personnel files to ensure completeness at he facility and the corporate office. Required trainings are documented and filed for personnel file # 5. Personnel file # 6 is no longer with the agency. Full compliance will be met effective 09/03/2010. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
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.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, completed by the facility on June 8, 2010 and an interview with the facility director, the facility failed to have at least one Full-Time Equivalent (FTE) counselor for every eight (8) clients.
The findings include:
The actual client to counselor ratio is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients ' treatment by the facility's standard workweek.
The facility ' s standard work week, as reported on the Staffing Requirements Facility Summary Report, was 40 hours per week.
On June 8, 2010 the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed employee #3 (clinical supervisor), employee #4 (program supervisor/clinical supervisor), employee #5 (counselor II), employee #6 (counselor I), employee #7 (counselor), employee #8 (counselor), employee #9 (counselor assistant) for the clinical staff; however, employees #7 & 9 were not able to be counted in calculating the ratio. The facility lacked documentation for employee #7 to verify a degree to meet the qualifications for the position of counselor and employee # 9 was a counselor assistant that was still in the direct observation period.
Based the total number of hours per week that the facility reported the clinicians devoted to their clients (160), the total number of hours in the facility ' s standard work week (40), and the total number of active clients (38) on June 8, 2010, the facility failed to ensure that there was one FTE counselor for every eight clients. The Staffing Requirements Facility Summary Report indicated the client to counselor ratio was 10 clients for each FTE counselor.
160 hrs/40 hr workweek = 4 FTE 38 clients/4 FTE = 9.5 or 10:1.
The facility director signed the Staffing Requirements Facility Summary Report on June 8, 2010, to attest to the accuracy, veracity, and authenticity of the stated information.
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Plan of Correction
The facility will maintain compliance based on Staffing Requirements Facility Summary report. There will be one full-time counselor for every eight (8) clients. This standard will be in place by September 3, 2010. If the counselor/client begins to fall out of compliance, the managers will assume the role of clinicians until the counselor/client ratio is once again in compliance. This will be monitored by the Program Director, Clinical Supervisor and the Division Director for a period of not less than three months and on a quarterly basis thereafter.
The facility will obtain the documentation for employee #7 to verify a degree to meet the qualifications for the position of counselor. Employee # 9, counselor assistant, will have direct supervision the will be documented by the clinical supervisor. This will be monitored by the program director for a period of not less the three (3) months and on a quarterly basis thereafter. This standard will be in place no later than September 3, 2010.
Hiring managers, the division director and human resources will assure the all staffing requirements are in compliance based on the Staffing Requirements Facility Summary Report.
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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.
The findings include:
A tour of the facility's physical plant was conducted on June 8, 2010 at approximately
2:00 PM. The facility was required to secure all client records within locked storage containers. At the time of inspection, the facility did not have all client records stored within a locked storage container.
On the 4th floor, client records were stored in an unlocked file cabinet in a multipurpose closet.
On the 3rd floor, client records were stored in boxes in an office.
This deficiency was cited previously on 6/16/09.
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Plan of Correction
All open client records will be kept in locked file cabinets in a locked closet. All closed client records will be keep in a locked storage bin, in a locked closet until they can be picked up for archiving. Clinical supervisor and program director will monitor this for a period of not less than three months on a daily basis and on a weekly basis thereafter. This standard will be met by September 3, 2010.
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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 the review of client records and an interview with the facility director, the facility failed to document informed and voluntary consent from the client for the disclosure of information contained in five of eight client records.
The findings include:
Eight client records were reviewed and an interview with the facility director was conducted on June 7-8, 2010. All eight records required documentation of informed and voluntary consent. The facility did not document informed and voluntary consent from the client for the release of information contained records # 4, 5, 6, 7 and 8.
The release forms disclosing information to a family member in client records # 4, 5 and 7 did not include a statement informing the client of his/her right to verbally revoke the consent releasing information. The facility documented that the client must revoke the consent in writing.
The release forms disclosing information to a probation/parole officer in client records # 5 and 6 did not include a statement informing the client of his/her right to verbally revoke the consent releasing information. The facility documented that the client must revoke the consent in writing.
The release forms disclosing information to a social service agency in client records # 7 and 8 did not include a statement informing the client of his/her right to verbally revoke the consent releasing information. The facility documented that the client must revoke the consent in writing.
Additionally, all of these consent forms releasing client information contained language indicating the clients records could be released with verbal consent.
The Consent to Release Information form stated:
" I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written or verbal consent unless otherwise provided for in the regulations. "
This was confirmed by the facility director.
This deficiency was cited previously on 6/16/09.
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Plan of Correction
All disclosures of information contained in client records will contain informed and voluntary consent from the client for the release of confidential information. All disclosures of information contained in client records will specify that the client can revoke the disclosure verbally or in writing. This standard will be met by September 3, 2010. All corrected disclosure of information forms will include, but not be limited to Family Releases of information, Parole/Probation Releases of Information, Funding Sources Releases of Information and Social Service Agencies Releases of Information. This will be monitored by the clinical supervisor and the program director on an on-going basis.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, a review of the client handbook and an interview with the facility director, the facility failed to demonstrate efforts towards informing clients of their rights in eight of eight records.
The findings include:
Eight client records were reviewed on June 7-8, 2010. The facility did not document a complete list of client rights in the client handbook or on the client rights sign-off in records # 1, 2, 3, 4, 5, 6, 7 and 8.
The client rights did not include:
The client has the right to appeal a decision limiting access to his/her records to the project director.
The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
The client has the right to submit rebuttal data or memoranda to his own records.
An interview with the facility director was conducted on June 8, 2010. The facility director confirmed that the client handbook and the client rights sign-off did not include a complete list of client rights.
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Plan of Correction
The clients rights handbook will be revised to indicate the following:
The client has the right to appeal a decision limiting access to his/her records to the project director.
The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
The client has the right to submit rebuttal data or memoranda to his own records.
These client rights standards (completed list) will be placed in the client handbook no later than September 3, 2010. The program director will assure that the appropriate parties involved in the creation of the client handbook, will have this task completed. All clients will receive a revised handbook and a sign off sheet indicating that they have received it. The program director will monitor this, and will also sign off on this document giving assurance that it has been revised and re-distributed to all clients.
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on a review of client records, a review of the client handbook and an interview with the facility director, the facility failed to demonstrate efforts towards informing clients of their right to appeal a decision limiting access to their records to the project director in eight of eight records.
The findings include:
Eight client records were reviewed on June 7-8, 2010. The facility did not document a complete list of client rights in the client handbook or on the client rights sign-off in records # 1, 2, 3, 4, 5, 6, 7 and 8.
The client rights did not include:
The client has the right to appeal a decision limiting access to his/her records to the project director.
An interview with the facility director was conducted on June 8, 2010. The facility director confirmed that the client handbook and the client rights sign-off did not include the right to appeal a decision limiting access to his records to the project director.
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Plan of Correction
(4) The client has the right to appeal a decision limiting access to his/her records to the project director.
This client rights standard will be placed in the client handbook no later than September 3, 2010. The program director will assure that the appropriate parties involved in the creation of the client handbook, will have this task completed. All clients will receive a revised handbook and a sign off sheet indicating that they have received it. The program director will monitor this, and will also sign off on this document giving assurance that it has been revised and re-distributed to all clients.
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709.30(5) LICENSURE Client Rights
709.30. Client rights.
(5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
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Observations
Based on a review of client records, a review of the client handbook and an interview with the facility director, the facility failed to demonstrate efforts towards informing clients of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information from their records in eight of eight records.
The findings include:
Eight client records were reviewed on June 7-8, 2010. The facility did not document a complete list of client rights in the client handbook or on the client rights sign-off in records # 1, 2, 3, 4, 5, 6, 7 and 8.
The client rights did not include:
The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
An interview with the facility director was conducted on June 8, 2010. The facility director confirmed that the client handbook and the client rights sign-off did not include the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
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Plan of Correction
This client rights standard will be placed in the client handbook no later than September 3, 2010. The program director will assure that the appropriate parties involved in the creation of the client handbook, will have this task completed. All clients will receive a revised handbook and a sign off sheet indicating that they have received it. The program director will monitor this, and will also sign off on this document giving assurance that it has been revised and re-distributed to all clients.
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709.30(6) LICENSURE Client Rights
709.30. Client rights.
(6) The client has the right to submit rebuttal data or memoranda to his own records.
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Observations
Based on a review of client records, a review of the client handbook and an interview with the facility director, the facility failed to demonstrate efforts towards informing clients of their right to submit rebuttal data or memoranda to their own records in eight of eight records reviewed.
The findings include:
Eight client records were reviewed on June 7-8, 2010. The facility did not document a complete list of client rights in the client handbook or on the client rights sign-off in records # 1, 2, 3, 4, 5, 6, 7 and 8.
The client rights did not include:
The client has the right to submit rebuttal data or memoranda to his own records
An interview with the facility director was conducted on June 8, 2010. The facility director confirmed that the client handbook and the client rights sign-off did not include the right to submit rebuttal data or memoranda to his own records.
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Plan of Correction
This client rights standard will be placed in the client handbook no later than September 3, 2010. The program director will assure that the appropriate parties involved in the creation of the client handbook, will have this task completed. All clients will receive a revised handbook and a sign off sheet indicating that they have received it. The program director will monitor this, and will also sign off on this document giving assurance that it has been revised and re-distributed to all clients.
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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 the review of client records, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in three of eight client records.
The findings include:
Eight client records were reviewed on June 7-8, 2010. The facility did not document a treatment plan to include type and frequency of treatment services, as per facility policy, in client records # 1, 2, and 3.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. "
In client record #1, the treatment plan documented on 4/7/10 did not include type and frequency of treatment and rehabilitation services.
In client record #2, the treatment plan documented on 4/9/10 did not include type and frequency of treatment and rehabilitation services.
In client record #3, the treatment plan documented on 4/19/10 did not include type and frequency of treatment and rehabilitation services.
This deficiency was cited previously on 6/16/09,6/18/08, 8/30/07, 9/21/06, 8/4/05 &10/13/04.
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Plan of Correction
All treatment plans in client files will include type and frequency of treatment and rehabilitation services, as stated in the facilities policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN". Included in the action plan will be a statement of the type (individual/group/family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. This standard will be in place by September 3, 2010 and will be monitored by the Program Director and Clinical Supervisor for a period of not less than three months and on a weekly basis and ongoing thereafter.
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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 the review of client records, the facility failed to document a treatment plan to include a proposed type of support service in five of eight client records.
The findings include:
Eight client records were reviewed on June 7-8, 2010. The facility did not document a treatment plan to include a proposed type of support service, as per facility policy, in client records # 1, 2, 3, 7 and 8.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" The action plan will address the other support services in which the client is to participate including, but not limited to: medical, psychiatric, or psychological service, legal or economic assistance and Double Trouble and/or 12-step meeting attendance. "
In client record # 1, the treatment plan documented on 4/7/10 did not include support services.
In client record # 2, the treatment plan documented on 4/9/10 did not include support services.
In client record # 3, the treatment plan documented on 4/19/10 did not include support services.
In client record # 7, the treatment plan documented on 1/25/10 did not include support services.
In client record # 8, the treatment plan documented on 1/14/10 did not include support services.
This is a repeat citation from licensing inspection conducted on June 15-16, 2009 and the follow-up inspection conducted on November 4, 2009.
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Plan of Correction
All treatment plans in client files will include a proposed type of support service as per the facility policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN". The action plan will address the other support services in which the client is to participate including but not limited to: medical, psychiatric, or psychological service, legal or economic assistance and Double Trouble and/or 12 step meeting assistance. This standard will be in place by September 3, 2010 and will be monitored by the Program Director and Clinical Supervisor for a period of not less than three months and on a weekly basis and ongoing thereafter.
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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 the review of client records, the facility failed to document a treatment plan update in seven of eight client records.
The findings include:
Eight client records were reviewed on June 8-9, 2010. The facility did not document a treatment plan update, as per facility policy, in client records # 1, 2, 3, 4, 5, 6 and 8.
The facility ' s policy titled " Treatment Plan Reviews " states:
The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted.
In client record #1, the treatment plan was documented on 4/7/10, but a treatment plan update was not documented at the time of inspection on 6/8/10.
In client record #2, the treatment plan update documented on 4/30/10 did not include an assessment of progress.
In client record #3, the treatment plan update documented on 5/10/10 did not include an assessment of progress.
In client record #4, the treatment plan updates documented on 3/17/10, 4/17/10 and 5/15/10 did not include an assessment of progress.
In client record #5, the treatment plan updates documented on 4/8/10 and 5/15/10 did not include an assessment of progress.
In client record #6, the treatment plan updates documented on 4/14/10 and 5/15/10 did not include an assessment of progress.
In client record #8, the treatment plan updates documented on 2/3/10 and 3/11/10 did not include an assessment of progress.
This deficiency was cited previously on 6/16/09,8/30/07, 9/21/06 & 8/4/05.
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Plan of Correction
All client records will have documented treatment plan updates that will include the following as per the facility policy:
The counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter). This review shall include an assessment of the client's progress with the goals identified on the initial treatment plan.. This standard will be in place by September 3, 2010 and will be monitored by the Program Director and Clinical Supervisor for a period of not less than three months and on a weekly basis and ongoing thereafter.
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