INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 27, 2010 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 and a plan of correction is due on June 29, 2010.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report Form completed by the facility on May 27, 2010, and a discussion with the facility director, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Seven caseloads were reviewed on May 27, 2010.
Two counselors' had a caseload that was greater than 35:1.
Counselor # 2 had a caseload of 40:1, which exceeds the maximum of 35:1.
Counselor # 3 had a caseload of 55:1, which exceeds the maximum of 35:1.
This was confirmed by the facility director.
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Plan of Correction
All staff work 40 hours a week and their caseloads are no more than the approved staff to client ratio of 1 staff to 35 clients as of 6/15/10. At the time of the audit we had lost a counselor leaving us to short staffed. We ensured that clients were receiving the recommended services until a new counselor was hired. Since the audit we have hired a new counselor. Going forward policy 704.12 will be followed. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.
The findings include:
Two personnel records were reviewed on May 27, 2010 to verify that staff had been instructed in the use of a fire extinguisher upon employment..
The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 2 and 6.
Employee # 2 was hired on 1/2/09.
The training was due upon employment, the training was not documented at the time of review on 5/27/10.
Employee # 6 was hired 7/13/09.
The training was due within seven days of employment, the training was not documented at the time of review on 5/27/10.
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Plan of Correction
Employee #2 and #6 were trained on the use of a fire extingisher but it was not done within the appropriate time frame. All new employees wll be trained within the first week of hire. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, a review of the policies and procedures, and an interview with the facility director, the facility failed to document a comprehensive treatment and rehabilitation plan by the third session in accordance with facility's policy in three of seven client records.
The findings include:
Eight client records were reviewed on May 27, 2010 to ensure that a comprehensive treatment plan was completed by the third session.
Seven client records required documentation of a comprehensive treatment plan.
The facility did not document a comprehensive treatment plan per policy in three of seven records, as per facility policy, in client records # 1, 2, and 3.
The facility's policy states:
An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's initial interview, psycho-social evaluation, and other evaluations . The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social and assessment and the clients problem list. The plan will be discussed with the client and changes made upon client request as appropriate.
The treatment plan will be signed by the Client, the Primary Counselor, the Clinical Supervisor, physician(when applicable) and placed in the client record. Completion of the treatment plan will be noted in the counselor's progress note for that day of service, by the third session (outpatient).
Client # 1 was admitted to the facility on 10/27/09.
The preliminary treatment plan was complete on 10/27/09.
The comprehensive treatment plan was documented on 11/17/09, this was the 4th session.
Client # 2 was admitted to the facility on 12/9/09.
The preliminary treatment plan was complete on 12/9/09.
The comprehensive treatment plan was complete on 12/30/09, this was the 5th session.
Client # 3 was admitted to the facility on 4/30/10.
The preliminary treatment plan was complete on 4/14/10.
The comprehensive treatment plan was complete on 4/30/10, this was the 4th session.
The facility director confirmed that the comprehensive treatment plans were not complete by the third session.
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Plan of Correction
Policy has been changed to read that treatment plans will be completed within 30 days of admission to the program. All new staff will follow the orientation developed for new hires and will reflect that they have received the training. All staff have been trained to the new policy and we are currently using it in our program. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records and a review of the policies and procedures, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in two of five client records.
The findings include:
Eight records were reviewed on May 27, 2010.
Five records reviewed required treatment plan updates every sixty days per facility policy.
The facility failed to document a treatment and rehabilitation update per policy in client records # 1 and 8.
The facility's policy states:
709.92.b
Gaudenzia, Inc. Outpatient, will ensure treatment and rehabilitation plans will be reviewed and updated at least every sixty days. The treatment plan update will include an assessment of the client ' s progress in relationship to stated goals. Treatment plan updates will be signed and dated by the primary counselor and clinical supervisor. The following issues will be considered:
problems or issues identified in the treatment plan been impacted through treatment?
goals be revised or restated?
strategies or action steps need modification?
Client # 1 was admitted to the program on 10/27/09.
The comprehensive treatment plan was documented on 11/17/09.
Treatment plan updates were documented on 1/19/10 and 5/15/10.
Client # 8 was admitted to the program on 12/31/09.
The comprehensive treatment plan was documented on 1/14/10.
Treatment plan updates were documented on 3/18/10 and 4/9/10.
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Plan of Correction
Based on Gaudenzia's policy all updated treatment plans will be completed and signed by client, counselor and clinical supervisor within 60 days of the comprehensive. Clinical Supervisor will monitor the completion of documentation in a timely manner. The Clinical Supervisor will do weekly audits to ensure compliance. |
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 on the review of client records and a review of the policy and procedures manual, the facility failed to document follow-up information per policy in 1 of 3 client records.
The findings include:
Five closed client records were reviewed on May 27, 2010.
Three client records required documentation of follow-up information.
The facility failed to document follow-up per policy, in client record # 5.
The facility's policy on follow- up states:
All clients are followed up after discharge.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the outpatient program, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
Where clients are not referred after discharge, the administrative coordinator or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder..
Client # 5 was admitted to the facility on 10/8/09 and discharged on 11/30/09, follow-up was documented on 1/2/10.
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Plan of Correction
All clients that are discharged will be contacted within 30 days of discharge to follow up with their stats since leaving the facility. This call will be logged in a binder, maintained and monitored by the administrator. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a tour of the facility's physical plant, the facility failed to display the hours of operation conspicuously to the general public.
The findings include:
A tour of the facility's physical plant and an interview with the facility director was conducted on May 27, 2010 at approximately 4:30 PM.
The facility was required to display the hours of operation to the general public. The facility did not have the hours of operation posted conspicously to the general public.
The facility director confirmed that the hours of operation were not conspicuously displayed to the general public.
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Plan of Correction
Gaudenzia Coatesville hours are clearly located on the Gaudenzia sign located at the front door. |