INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from May 23-24, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia - New Destiny, 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(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 a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in one of four records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1's personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
The findings were reviewed with the human resources staff.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 and 2010 licensure inspections.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that the development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file. Individual Training Plans will be completed for all employees by January 31, 2013 as per policy. A training plan was completed for the corporate employee identified as deficient and dated in May 2012. The Director of Training and the Director of Human Resources will ensure that all corporate staff complete an annual training plan as per organization policy in January of each year and will monitor ongoing conformance. The Program Director will ensure that a training plan will be completed in January of each year per policy for each employee at the facility and will monitor ongoing conformance. Completion date?5/9/2012 |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of residents, employees and visitors.
The findings include:
The facility shares its outdoor outdoor recreational space and recreational equipment with another facility located on the same grounds.
The physical plant inspection of the outdoor recreational area was conducted on May 23, 2012.
The grass located in the recreational space was not cut at the time of inspection. In some spots the grass and a thistle plant were approximately 24 inches high. The uncut grass and weeds created a potential haven for insects and / or animals.
The facility failed to maintain the bathroom between rooms 7b and 8 in a safe manner and in good repair. The top of the wall mounted mirror in the bathroom between rooms 7b and 8 was broken.
The findings were confirmed by the Facility Director during the physical plant inspection.
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Plan of Correction
The Building exterior and grounds should be clean, safe, and sanitary at all times for the safety and well-being of residents, employees and visitors. . .
The grass and related weed removal will take place on a regular, contracted basis in order to maintain the outdoor play area in order to control pests and/or animals and create a safer, hazard-free environment. The area was mowed on the date of the site visit (5/23/12) and thereafter has been mowed and trimmed on a two-week contractual schedule. The Program Director will ensure bi-weekly grounds maintenance occurs and will ensure contracts are completed annually. Completed by July 1, 2012.
The bathrooms shall be maintained in a safe manner and good repair. On 5/23/12 the broken mirror was removed. The bathrooms between room have been specifically added to the house run check list to ensure the area is maintained in safe and good repair. The Program Director will review house run sheets on a weekly basis and the program director will make a weekly house run to ensure the accuracy of reports and inspect any follow-up repairs. Completed by 6/25/2012
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that there were slip-resistant surfaces in all bathtubs and showers.
The findings include:
The physical plant inspection was conducted on May 24, 2012.
The bathroom located between room # 5 and room # 7a contained a bathtub that did not have a slip-resistant surface.
The bathroom located between bedroom # 7b and room # 8 contained a bathtub that did not have a slip-resistant surface.
The findings were confirmed by the Facility Director during the physical plant inspection.
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Plan of Correction
The bathrooms shall be maintained in a safe manner and good repair. On 5/25 /12. There shall be slip resistant surfaces in all bathtubs and showers. Slip resistant surfaces were installed in the bathtubs between room #5 and room #7 and room #7a and room #8. Further, the house run check list has been amended to specifically include inspection of these bathrooms separately from the dorm bed areas in order to maintain the area in safe and good repair. The repair was completed 6/22/2012.
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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based upon a review of temperature logs, the facility failed to ensure that cold food was kept at or below 40 and frozen food at or below 0 findings include:
Temperature logs for two freezers and two refrigerators were reviewed on May 24, 2012. The facility failed to maintain frozen food at or below 0 degrees F in two of two freezers during the months of April and May 2012. In addition, the facility failed to maintain cold food at or below 40 degrees F in one of two refrigerators during the months of April and May 2012.
The following freezer temperatures were documented for the following dates and corresponding times:
Commissary Freezer
April 16 at 11:00pm = +2 degrees F
17 at 6:00am = +2 degrees F
18 at 11:55pm = +6 degrees F
20 at 6:30am = + 2 degrees F
28 at 11:15pm = +4 degrees F
29 at 6:00am = +4 degrees F
29 at 11:20pm = +2 degrees F
30 at 6:00am = +2 degrees F
May 9 at 6:30am = +20 degrees F
10 at 11:45pm = +20 degrees F
11 at 6:40am = +10 degrees F
11 at 11:10pm = +2 degrees F
12 at 6:00am = +2 degrees F
Kitchen Freezer
April 12 at 11:20pm = + 2 degrees F
13 at 6:30am = +2 degrees F
14 at 11:15pm = +14 degrees F
15 at 6:45am = +14 degrees F
16 at 11:00pm = +10 degrees F
18 at 11:55pm = +2 degrees F
20 at 6:30am = +4 degrees F
28 at 11:15pm = +5 degrees F
29 at 6:00am = +5 degrees F
29 at 11:20pm = +10 degrees F
30 at 6:00am = +10 degrees F
May 7 at 12:10am = +10 degrees F
10 at 11:45pm = +8 degrees F
11 at 11:10pm = +6 degrees F
12 at 6:00am = +6 degrees F
12 at 11:25pm = +12 degrees F
13 at 6:10am = +12 degrees F
13 at 11:45pm = +4 degrees F
The following refrigerator temperatures were documented for the following dates and corresponding times:
Kitchen Refrigerator
April 11 at 6:20am = 50 degrees F
12 at (no time) = 50 degrees F
18 at 5:35am = 44 degrees F
18 at 11:55pm = 44 degrees F
19 at 6:30am = 44 degrees F
20 at 12:15am = 46 degrees F
May 4 at 11:50pm = 48 degrees F
The findings were confirmed by the Facility Director following the physical plant inspection.
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Plan of Correction
Cold foods must be kept at or below 40 degrees F, hot food at or above 140 degrees F, and frozen food at or below 0 degrees. The Gaudenzia Facility Manager inspected the refrigerator and freezer (Commissary and Kitchen Freezer are the same freezer. Identifiers were changed when the freezer was moved from Commissary) on 7/5/2012 utilizing a digital infra-red thermometer and found the several thermometers present in the appliances were not registering correct temperatures by several degrees. The Gaudenzia Food Manager will order better calibrated thermometers in order to register accurate temperatures. Replacement of thermometers will occur by July 31, 2012. If replacements do not arrive before this date, they will be purchased locally. House Managers will continue to monitor temperatures twice daily and any problems with the range will be reported to the Program Director who will take action to secure repairs or replacement. Completed by 7/31/2012. |
705.11 (1) (i) LICENSURE Child care.
705.11. Child care.
When a residential facility admits children for services or for custodial care, the following requirements apply:
(1) Building exterior and grounds. The residential facility shall:
(i) Fence off or have natural barriers to protect children from all areas determined to be unsafe including steep grades, cliffs, open pits, swimming pools, high voltage boosters or roads.
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Observations
Based upon Licensing Staff observation and the physical plant inspection, the facility failed to fence off or have natural barriers to protect children from all areas determined to be unsafe including steep grades, cliffs, open pits, swimming pools, high voltage boosters or roads.
The findings include:
The physical plant inspection was conducted on May 24, 2012.
During the inspection, the Licensing Specialist observed a child run across the facility's access road and then walk around a vehicle parked next to a steep grade.
An inspection of the main entrance to the facility, the access road, and the steep grade, revealed that once a child exits the building there is no fence or natural barrier to prevent them from running across the road or protect them from falling down the steep grade.
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
Building exterior and grounds shall have a fence or natural barriers to protect children from all areas determined to be unsafe including steep grades, cliffs, open pits, swimming pools, high voltage boosters or roads. The Gaudenzia Facility Manager will complete a feasibility study by August 15, 2012, regarding constrction of a barrier between the entrance of New Destiny and the parking lot/road to impede the exodus of children from the building. The barrier will tie into the playground. A barrier will be installed consisting of poles, chain and signage in the area of the steep grade. The project will be engaged and completed by August 31, 2012. On June 26, 2012, clients were reminded children were not permitted in the smoking area and may only be in the playground when accompanied by an adult. This rule is being added to the Orientation Handbook. Clients will recieve a copy of the changed written rule and will sign-off to indicate an understanding and receipt of the rule. This will be accomplished by July 30, 2012. Completion date: August 31, 2012. |
705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based upon the physical plant inspection, the facility failed to maintain security screens or safety locks for all operable windows.
The findings include:
The physical plant inspection was conducted on May 24, 2012.
The window located in the stairwell between the 1st floor and 2nd floor was operable but did not contain a security screen.
A window located in the women's lounge on the 2nd floor was operable but did not contain a security screen.
The findings were reviewed with the Facility Director during the physical plant inspection.
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Plan of Correction
The residential facility shall maintain security screens or safety locks for all operable windows. During a routine house run, screens were removed from the window located in the stairwell between the 1st and 2nd floor for repair and the living room area. The screens were repaired and returned to the windows on 5/26/2012. The Program Director shall insure that windows are locked or sealed when screens must be removed for any reason. Completed 5/26/12. |
705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based upon the physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.
The findings include:
The physical plant inspection was conducted on May 24, 2012.
Protective caps were missing over electrical outlets in the following locations:
2nd Floor
Kitchen - bottom cap missing from one outlet.
Bathroom - upper cap missing from outlet next to sink.
Group room on left side of hallway - both caps missing from one outlet.
3rd Floor
Bedroom # 1 - 1 upper and 1 lower cap missing from 2 different outlets.
Bedroom # 2 - 1 upper and 2 lower caps missing from 2 different outlets.
Bedroom # 4 - 1 upper and 1 right side cap missing from 2 different outlets.
Bedroom # 6 - 2 upper caps missing from 2 different outlets.
Bathroom located between bedrooms # 5 and # 7a - 1 right side cap missing.
Bathroom located between bedrooms # 7b and # 8 - 4 caps missing from 2 outlets.
The findings were confirmed by the Facility Director during the physical plant inspection.
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Plan of Correction
The residential facility shall maintain protective caps over each electrical outlet. All electrical outlets were covered on 5/25/12. On 6/6/612 a new house run sheet was developed to check and account for safety outlet covers in each room and to note when a replacement was made. In addition, all residents were informed as to their responsibility to maintain and replace outlet covers removed during June 6, 2012 Community Meeting. All house managers reviewed the new house run sheets before use was instituted on June 6, 2012. Completed July 1, 2012. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relative policies in the Gaudenzia Policy and Procedure Manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility clinical meeting by the Program Director in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthy CQI analysis. These policies will be revised and approved by July 31, 2012. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based upon a review of administrative documentation, the facility failed to maintain a written agreement with a licensed hospital or physician, to provide for 24-hour emergency medical coverage.
The findings include:
The facility's referral agreements were reviewed on May 24, 2012.
The facility was unable to provide documentation of a written agreement with a licensed hospital or physician, to provide for 24-hour emergency medical coverage.
The findings were confirmed by the Facility Director during the exit interview.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the June 2, 2011 licensure inspection.
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Plan of Correction
Provisions shall be made, through written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage. New referral agreements will be sent to providers of 24 hour emergency psychiatric and medical care no later than 7/13/2012. Follow-up will ensure that the agreement is returned no later than 8/15/2012.The agreement will be renewed every two years. The Program Director will ensure compliance with this standard. Completed by 8/15/2012.
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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/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner. The Financial Audit for Fiscal Year 2011-2012 will be completed within six (6) months after June 30th close of Gaudenzia's fiscal year (by December 31, 2012) as per Chapter 709.25(a). Completion date?12/31/2012
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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 upon a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
The findings include:
Nine client records requiring documentation of informed and voluntary consent forms were reviewed on May 24, 2012. Four of nine records, specifically record # ' s 1, 5, 6, and 7, either contained consent forms that were signed after disclosures were made, or did not contain a consent form at all relevant to disclosures that were made.
Client # 1 was admitted on February 6, 2012, and was still a client on the date of inspection. The record contained documentation of a disclosure that was made to the funding source on February 21, 2012. However, the consent form for the funding source was not signed by the client until February 26, 2012.
Client # 5 was admitted on January 4, 2012, and was discharged on May 10, 2012. The record contained documentation of a disclosure that was made to the funding source on January 5, 2012. However, the consent form for the funding source was not signed by the client until January 15, 2012.
Client # 6 was admitted on January 11, 2012, and was discharged on March 17, 2012. The record contained documentation of a disclosure to a housing agency on January 23, 2012, and again on March 13, 2012. However, the record did not include documentation of a consent form for the recipient.
Client # 7 was admitted on December 27, 2011, and was discharged on March 26, 2012. The record contained documentation of a disclosure to a housing agency on January 10, 2012. However, the record did not include documentation of a consent form for the recipient.
The findings were confirmed by the Facility Director during the record review.
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Plan of Correction
A copy of any and all consent forms signed by the client while undergoing treatment (intake through discharge) should be maintained in the client file. All clinical and administrative staff reviewed this requirement with the Program Director on June 21, 2012. Regulations regarding consents will be offered in an in-service training no later than July 31 and sign-off sheets will be completed indicating an understanding of these regulation and procedures. No information may be released to any source without the prior consent of the client and all consents will be signed prior to providing information to any source. This will be monitored by the Program Director through case reviews and through clinical and administrative meetings on a monthly basis. Completion date?7/31/2012.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to document physical examinations as per facility policy.
The P&P Manual was reviewed from May 1-2, 2012.
The facility policy titled, "Physical Examination Laboratory Studies" included the following language:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend."
Nine records requiring documentation of physical examinations were reviewed on May 24, 2012. Six of nine records, specifically #s 1, 2, 3, 5, 7, and 9, either contained documentation of physical exams that were not completed per policy, or did not contain documentation of a physical exam.
Client # 1 was admitted on February 6, 2012, and the physical exam was due by February 13, 2012. The physical exam was late as it was not completed until February 22, 2012.
Client # 2 was admitted on March 5, 2012, and the physical exam was due by March 12, 2012. The physical exam was late as it was not completed until March 20, 2012. In addition, the physical exam was documented by a physician's assistant but never countersigned by a supervising physician.
Client # 3 was admitted on March 21, 2012, and the physical exam was due by March 28, 2012. The physical exam was documented for March 26, 2012, but was completed by a physician's assistant and never countersigned by a supervising physician.
Client # 5 was admitted on January 4, 2012, and the physical exam was due by January 11, 2012. The physical exam was late as it was completed on February 8, 2012.
Client # 7 was admitted on December 27, 2011, and was discharged on March 26, 2012. The physical exam was due by January 4, 2012, (one additional day added due to holiday), but was not completed until January 13, 2012. In addition, the physical exam was documented by a physician ' s assistant but never countersigned by a supervising physician.
Client # 9 was admitted on September 21, 2011, and discharged on January 3, 2012. The physical exam was due by September 28, 2011; however, the record did not contain documentation of a physical examination as of the date of inspection.
The findings were reviewed with the Facility Director during the exit interview.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the June 2, 2011 licensure inspection.
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Plan of Correction
Intake procedures shall include documentation of Physical examination by a qualified physician within 7 days of admission, except on holiday or weekend. Clinical staff reviewed the findings and will schedule physicals to take place within 7 days of admission with a qualified physician. The Case Manager and Program Director are responsible for review of each file to ensure compliance. Reports will be made at CQI meetings. Completed by 7/15/12. 2012 |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to document preliminary treatment plans as per facility policy.
The findings include:
The P&P Manual was reviewed from May 1-2, 2012.
The policy titled, "Clinical Level System - Women with Children" included the following language:
"12. Complete the screening/bio-psycho-social/client list and initial treatment plan by day 3."
Nine records requiring documentation of initial treatment plans were reviewed on May 24, 2012. Three of nine records, specifically # ' s 2, 3, and 9, did not contain documentation of initial treatment plans as per facility policy.
Client # 2 was admitted on March 5, 2012, and was still an active client on the date of inspection. The initial treatment plan was due no later than March 8, 2012; however, the record did not contain documentation of an initial treatment plan as of the date of inspection.
Client # 3 was admitted on March 21, 2012, and was still an active client on the date of inspection. The initial treatment plan was due no later than March 24, 2012; however, the record did not contain documentation of an initial treatment plan as of the date of inspection.
Client # 9 was admitted on September 21, 2011, and was discharged on January 3, 2012. The initial treatment plan was due no later than September 24, 2011; however, the record did not contain documentation of an initial treatment plan as of the date of inspection.
The findings were confirmed by the Facility Director during the exit interview.
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Plan of Correction
Counselors will complete the screening/bio-psycho-social list and initial treatment plan by day 3. The initial treatment plan will be completed and signed by client, counselor and Program Director by day 3. In addition, an Individual Counseling Session will document the completion of the bio-psycho-social and initial treatment plan. Counselors and Program Director met on 6/29/2012 to review this policy. Counselors will sign-off to indicating an understanding of this regulation. Program Director is responsible for reviewing each initial plan and ensuring compliance. A report will be made monthly as part of the CQI process regarding compliance. Completed by 7/31/12. |
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 upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to update treatment and rehabilitation plans as per facility policy.
The findings include:
The P&P Manual was reviewed from May 1-2, 2012.
The policy titled, "Intake Process/Paperwork" and subtitled, "Treatment Plan Reviews" included the following language:
"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 treatment plan along with a specific indication of how each goal has been impacted. Any goal or action step additions, revisions and deletions shall also be reflected. Goal and action step changes shall also be reflected on the treatment plan."
Nine records requiring documentation of treatment plan updates were reviewed on May 24, 2012. Four of nine records, specifically record #s 2, 4, 6, and 9, contained updated treatment plans that were completed late, contained updates that did not include assessments of client's progress, or they did not contain updated treatment plans at all.
Client # 2 was admitted on March 5, 2012, and was still an active client on the date of inspection. The record contained a treatment plan dated March 9, 2012, and updated treatment plans dated April 9, 2012, and May 5, 2012. However, neither update contained an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal had been impacted.
Client # 4 was admitted on March 2, 2012, and was still an active client on the date of inspection. The record contained a treatment plan dated March 5, 2012, and an updated treatment plan dated May 2, 2012. However, the update did not contain an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal had been impacted.
Client # 6 was admitted on January 11, 2012, and was discharged on March 17, 2012. The record contained a treatment plan that was dated January 13, 2012, and an updated treatment plan that was dated February 14, 2012. The updated treatment plan was late as it was due on or by February 12, 2012. In addition, the record was missing an updated treatment plan that was due on or by March 15, 2012.
Client # 9 was admitted on September 21, 2011, and was discharged on January 3, 2012. The record contained a treatment plan that was dated September 27, 2011, and updated treatment plans for October and November of 2011. However, the record was missing an updated treatment plan that was due on or by December 22, 2011.
The findings were confirmed by the Facility Director during the record review.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
Counselors shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan. The 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. Any goal or action step additions, revisions and deletions shall also be reflected Goal and action step changes shall also be reflected on the treatment plan. Counselors were initially informed of the importance of updating treatment plans in a timely and effective manner and of documenting goal achievement, revisions etc. on June 22, with more in-depth in-service training on the correct usage of the treatment plan planned by August 15. The Program Director will complete a Gaudenzia Training Institute training on Record Keeping on August 2 and August 3 in order to better present information to counselors. Counselors will participate in an in-service following this training and will sign that they have participated and understand the information presented. The monthly review of files by the program director will better document quality of treatment plans by examination of how goal completion, goal revision, and changes of action steps are documented. In addition, counselors having problems meeting this standard may have a Plan of Improvement implemented in order to meet compliance. The outcome will be reported for the Monthly CQI meetings and the findings will be reviewed with clinical staff. Completed by 8/15/2012.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed assure that counseling services were provided as per the individual treatment plan and facility policy.
The findings include:
The P&P Manual was reviewed from May 1-2, 2012.
The policy titled, "Counseling Services" included the following language:
"- Counseling services shall be provided for each client according to the frequency and nature identified on the client's individualized treatment and rehabilitation plan.
- Individual counseling ..... shall be documented in the client record in an Individual Counseling Progress Note. (Residential DOH, PA)
- All therapy services shall be noted on the Record of Services Provided form."
Nine records requiring documentation of counseling services received by clients were reviewed on May 24, 2012. Two of nine records, specifically #'s 2 and 3, did not contain documentation that demonstrated that counseling sessions were provided as per the treatment plan.
Client # 2 was admitted on March 5, 2012, and was still an active client on the date of admission. The record contained a treatment plan that was signed by the client on March 9, 2012. The treatment plan specified that the client would receive 1 group counseling session per week and 2 individual sessions per month. The record did not contain individual counseling progress notes for the month of April 2012. In addition, the record contained a 'record of services' that did not contain documentation of individual sessions for the month of April 2012.
Client # 3 was admitted on March 21, 2012, and was still an active client on the date of admission. The record contained a treatment plan that was signed by the client on March 25, 2012. The treatment plan specified that the client would receive 1 group counseling session per week and 2 individual sessions per month. The record did not contain individual counseling progress notes for the month of April 2012. In addition, the record contained a 'record of services' that did not contain documentation of individual sessions for the month of April 2012.
The findings were confirmed by the Facility Director during the record review.
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Plan of Correction
Counseling services shall be provided for each client according to the frequency and nature identified on the client's individualized treatment and rehabilitation plan. Individual counseling...shall be documented in the client record in an Individual Counseling Progress Note. All therapy services shall be noted on the Record of Services Provided form. Counselors were informed of the lack of documentation on 5/25/2012 following the survey. The counselor of record for files for Client #2 and #3 had neglected to present the forms to the Program Director for signatures and had not placed the progress notes to be filed. Upon informing of the lack of documentation, the progress notes were filed on 5/25/2012. Both counselors were informed of the need to complete, have signed and filed all progress notes in a timely and effective manner. Each month. 50% of the files will be reviewed by the program director as part of the CQI process to ensure compliance and report submitted to the CQI committee as well as reviewed with clinical staff. Completed by 7/31/2012 (next CQI review).
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