INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Inc. 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 licensure inspection.
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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 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 31st, 2013 as per our 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.
Target resolution date: Resolved.
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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 relevant 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's staff meetings by the Program Director and/or Program Supervisor 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 monthly CQI analysis." These policies will be revised and approved by July 31st, 2012. |
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 6 months after the June 30th close of Gaudenzia's fiscal year (by December 31st, 2012) as per Chapter 709.25(a). |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation that included an assessment of the client's composite picture, assets and strengths, support systems, coping mechanisms, negative factors that may affect treatment, or failed to document a biopsychosocial evaluation at all.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of psychosocial assessments:
"Psychosocial Assessment:
Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weaknesses, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client ' s strengths, abilities and preferences...
The assessment shall be submitted promptly to the Clinical Supervisor for review and signature...within 3 individual sessions for outpatient."
Five client records were reviewed for psychosocial evaluations on June 1, 2012. Four out of five client records lacked documentation of a psychosocial evaluation that was in accordance with the facility's policies and procedures, specifically client records #1, 2, 3, and 5.
Client #1 was admitted to treatment on February 17, 2012. The psychosocial evaluation was completed on February 10, 2012 and did not include the client's composite picture or a clinical assessment of the client's coping mechanisms.
Client #2 was admitted to treatment on February 22, 2012. The psychosocial evaluation was completed on January 23, 2012 and did not include the client's composite picture or a clinical assessment of the client's coping mechanisms.
Client #3 was admitted to treatment on February 22, 2012. The client had individual sessions documented on 2/22/12, 3/7/12, 3/13/12, and 4/18/12. The psychosocial evaluation should have been completed by March 13, 2012. The psychosocial evaluation was completed on April 18, 2012 and did not include the client's composite picture, a clinical assessment of the client's coping mechanisms, or negative factors that may affect treatment.
Client #5 was admitted to treatment on December 2, 2011 and discharged on February 29, 2012. The psychosocial evaluation was completed on November 7, 2011 and did not include a clinical assessment of the client's assets and strengths, support systems, coping mechanisms, or negative factors that may affect treatment.
The findings were reviewed with the acting facility director during the exit interview.
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Plan of Correction
All clients will have a completed psychosocial evaluation that includes an assessment of the client's composite picture, assets and strengths, support systems, coping mechanisms and negative factors that effect treatment. It will also include a narative assessment consisting of client description, referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client's strengths and weaknesses, client motivation, support systems, client's responses during the intake, receptivity to treatment, client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. All this is to be submitted to the clinical supervisor for review and signature within 3 individual sessions.
Clinical supervisor will review all psychosocial evaluations for completeness and thoroughness. If acceptable it will be signed and dated by the clinical supervisor to become part of the client record. If in need of revision, it will be returned to counselor with an expected date to be completed and re-submitted to the supervisor for approval and signature.
Clinical supervisor and Division Director will neet with counselors to review the psychosocial evaluations and assessments, step by step in an in-service training scheduled on July 17, 2012. At this time, clinical staff will sign a statement that they have received the training and understand what is expected.
In addition, Clinical Supervisor and Division Director will review active client charts on a monthly basis for completeness and quality, and submit results in a Quality Assurance report. This report will be submitted to the Corporate office and the results will be shared with the clinical staff. |
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 upon a review of the facility's policies and procedures and client records, the facility failed to develop individual treatment and rehabilitation plans as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012 and May 7-9, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of treatment plans.
"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...."
Four client records requiring documentation of individualized treatment plans were reviewed on June 1, 2012. Two of four client records did not have documentation of a treatment plan, specifically #'s 3 and 5.
Client #3 was admitted to treatment on February 22, 2012. The client had individual sessions documented on 2/22/12, 3/7/12, 3/13/12, and 4/18/12. The individualized treatment plan should have been completed by March 13, 2012. As of the date of inspection, there was no documentation of a treatment plan for client #3.
Client #5 was admitted to treatment on December 2, 2011 and discharged on February 29, 2012. The client had individual sessions documented on 12/2/11, 1/10/12, 1/18/12, 1/25/12, 2/7/12, 2/15/12 and 2/29/12. The individualized treatment plan should have been completed by January 18, 2012. As of the date of inspection, there was no documentation of a treatment plan for client #5.
The findings were reviewed with the acting facility director during the exit interview.
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Plan of Correction
All client treatment and rehabilitation plans shall be developed with the client and submitted to the Clinical Supervisor by the counselor. Completed treatment plans should be approved and signed by the counselor, Clinical Supervisor and Medical Director by the second or third counseling outpatient appointment.
Clinical Supervisor and Division Director will meet with counselors to review the preparation of the treatment plan and all components in an in-service training on July 17, 2012. All clinical staff will sign a statement that they attended the training and understand what is expected.
In addition, Division Director and Clinical Supervisor will review active client charts monthly to ensure completeness and quality of the plan. These results will be submitted in a Quality Assurance report to the Corporate office and shared with clinical staff. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document case consultations as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of case consultations:
"Case Consults are performed every 90 days for outpatient. Case Consults are performed more frequently whenever a client has a special problem (s). The Counselor shall meet with the Clinical Supervisor on a regular scheduled basis, i.e., weekly or bi-weekly, to discuss the overall progress or problems of each client. Documentation of the case consults shall be completed by the primary Counselor. "
Three client records requiring documentation of case consultations were reviewed on June 1, 2012. Three of three client records, did not have documentation of a case consultation, specifically #'s 1, 2, and 3.
Client #1 was admitted to treatment on February 17, 2012. A case consultation was due by May 17, 2012 for client #1. As of the date of inspection, there was no documentation of a case consultation for client #1.
Client #2 was admitted to treatment on February 22, 2012. A case consultation was due by May 22, 2012 for client #2. As of the date of inspection, there was no documentation of a case consultation for client #2.
Client #3 was admitted to treatment on February 22, 2012. A case consultation was due by May 22, 2012 for client #3. As of the date of inspection, there was no documentation of a case consultation for client #3.
The findings were reviewed with the acting facility director prior to the exit interview.
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Plan of Correction
All active clients will have case consultations completed every 90 days and more often whenever a client has a special problem.
Counselors and Clinical Supervisor will meet on a weekly basis to discuss the overall progress or problem of each client. The primary counselor is responsible to complete the case consultation documentation. This documentation is to include : date of consult, names of attending staff and titles, client name, summary of discussion and disposition of case reviewed. The case consult will be signed by the primary counselor and reviewed for thoroughness and completeness and signed by the Clinical Supervisor.
Clinical Supervisor and Division Director will meet with clinical staff for an in-service training to review completing a case consult form on July 17. Clinical staff will sign a statement that have received the training and understand what is expected.
Division Director and Clinical Supervisor will also review client files monthly for Quality Assurance and report results to staff and the Corporate office. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document follow-up information as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of follow-ups:
" Follow Up:
Within seven (7) days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate. In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted within 30 days directly by the counselor or supervisor ' s designee... "
Two client records requiring documentation of a follow-up were reviewed on June 1, 2012. Two out of two client records did not have documentation of a follow-up according to the facility's policies and procedures, specifically #'s 4 and 5.
Client #4 was admitted to treatment on November 15, 2011 and discharged on January 17, 2012. No referral was made. A follow-up was due by February 17, 2012 for client #4. The follow-up for client #4 was documented on February 29, 2012.
Client #5 was admitted to treatment on December 2, 2011 and discharged on February 29, 2012. No referral was made. A follow-up was due by March 29, 2012 for client #5. The follow-up for client #5 was documented on April 4, 2012.
The findings were reviewed with the acting facility director during the exit interview.
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Plan of Correction
Client follow up will occur within 7 days after a client has been discharged from our program and referred to another agency. The purpose of the follow up is to determine whether the client kept their initial appointment and if the referral was appropriate. This contract will be documented and placed in the facility follow-up binder. If a client has not be referred to another agency after discharge, a follow up call will be made to the client within 30 days by the designated staff person. The completed form will be placed in the follow up binder.
This procedure will be reviewed with staff on July 17, 2012. Staff will sign a statement that they received, understand and will adhere to the follow up policy.
Division Director and Clinical Supervisor will review follow ups on a monthly basis to ensure compliance. |