INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 22 & 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. People With Hope/Short-Term Program 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 3, 2010.
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Plan of Correction
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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 the 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 21, 2009. One employee was identified as a counselor assistant and required direct observation supervision. The facility did not document direct observation for personnel #6.
Personnel #6 was hired on 1/22/10 as a counselor assistant with an Associate ' s degree and no previous clinical experience.
Personnel #6 was required to counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first nine months of employment.
The documented supervision notes for personnel #6 did not indicate if direct observation was occurring.
The clinical supervisor confirmed that direct observation for personnel #6 had not been documented.
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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 employee #6 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. |
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 one of one records.
The findings include:
Three personnel training records were reviewed on May 7, 2010. Of the three records reviewed, one was identified as a counselor during the 2009 training year and required at least 25 clock hours of training. The facility did not document at least 25 hours of training for personnel #4 during the 2009 training year.
The training record for personnel #4 contained 17 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 17 hours of training had been documented for personnel #4.
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Plan of Correction
A training will be held with all program staff to review what the specific number of training hours that are required for each staff member. This training will include review of training plans and mandatory trainings as required by state standards. To date employee #4 has not completed 25 hours of training for the training year. This employee will complete required training for this current training year. Clinical supervisor will be responsible for supervisory follow up and program director will be responsible for oversight. |
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 seven of thirteen client records.
The findings include:
Thirteen client records were reviewed and an interview with the facility director was conducted on June 21, 22 & 28, 2010. All thirteen 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 # 1, 2, 3, 4, 5, 6 and 7.
The release forms disclosing information to a family member in client records # 1, 2, 3, 4, 5, 6 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 funding source in client records # 1, 2, 3, 4, 5, 6 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 facility director confirmed that the release forms stated the client must revoke his/her consent to in writing.
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Plan of Correction
Program director will meet with staff and hold training on confidentiality. The training will focus on informed and voluntary consent for the disclosure of information. In addition training around proper documentation stating the right of a client to revoke consent verbally or in writing will take place. Any necessary changes will be made to forms in regard to this standard including where possible records # 1,2,3,4,5,6 and 7. Clinical supervisor will be responsible for supervisory follow up and program director will be responsible for oversight. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in six of thirteen client records.
The findings include:
Thirteen client records were reviewed on June 21, 22 & 28, 2010. All thirteen records required a psychosocial evaluation. The facility did not document a psychosocial evaluation within 5 days, as per facility policy, in client records # 8, 9, 10, 11, 12 and 13.
The facility ' s policy titled " DELIVERY OF REHABILITATION CLINICAL PROCESSES & PROCEDURES " states:
" The biopsychosocial, with accompanying assessment and diagnostic summary must be completed within 3-5 days of the client's admission. The QI Committee reviews every fourth client per counselor to ensure that the biopsychosocial is comprehensive, that the initial assessments and diagnostic summary are formulated upon information that is contained in the biopsychosocial and that the proposed initial individualized treatment plan is relevant to the content of the data assessed. "
The admission date for client #8 was 5/17/10, but a biopsychosocial evaluation was not documented at the time of review on June 28, 2010.
The admission date for client #9 was 5/18/10, but a biopsychosocial evaluation was not documented at the time of review on June 28, 2010.
The admission date for client #10 was 5/18/10, but a biopsychosocial evaluation was not documented at the time of review on June 28, 2010.
The admission date for client #11 was 6/15/10, but a biopsychosocial evaluation was not documented at the time of review on June 28, 2010.
The admission date for client #12 was 5/21/10, but a biopsychosocial evaluation was not documented at the time of review on June 28, 2010.
The admission date for client #13 was 6/21/10, but a biopsychosocial evaluation was not documented at the time of review on June 28, 2010.
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Plan of Correction
The clinical supervisor will train appropriate staff on completing the biopsychosocials and individualized comprehensive treatment plans for clients within 30 days of corrective action date. CLients #8, 9, 10, 11, 12 & 13,have all been discharged, and therefore making it unable for documented to be completed. The Clinical Supervisor will assure that biopsychosocials and individualized comprehensive treament plans are being done in a timely fashion by monitoring clinical staff via weekly supervision sessions and weekly auditing of client files. Chart audits will continue to be conducted for a period of not less that three months to assure consistency and facility compliance with this standard. CLinical Supervisor will also conduct random audits of client charts on a quarterly basis making certain that compliance continues to be maintained in regards to making certain biopsychosocials, with accompanying assessments and diagnostic summararies are completed within 3 to 5 days of the client's admission as stated in the facility policy. Clinical Supervisor will be responsible for supervisory follow up of clinical staff and Program Director will be responsible for oversight. Furthermore, the director of CQI will monitor the program on a quarterly basis |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on the review of client records, the facility failed to document an individual treatment plan in six of thirteen client records.
The findings include:
Thirteen client records were reviewed on June 21, 22 & 28, 2010. All thirteen records required an individual treatment plan. The facility did not document a treatment plan, as per facility policy, in client records # 8, 9, 10, 11, 12 and 13.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. 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 client ' s 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, within 3 days of admission (residential) or by the third session (outpatient).Chesapeake region requires an initial TP within 24 hours). "
The admission date for client #8 was 5/17/10, but an individual treatment plan was not documented at the time of review on June 28, 2010.
The admission date for client #9 was 5/18/10, but an individual treatment plan was not documented at the time of review on June 28, 2010.
The admission date for client #10 was 5/18/10, but an individual treatment plan was not documented at the time of review on June 28, 2010.
The admission date for client #11 was 6/15/10, but an individual treatment plan was not documented at the time of review on June 28, 2010.
The admission date for client #12 was 5/21/10, but an individual treatment plan was not documented at the time of review on June 28, 2010.
The admission date for client #13 was 6/21/10, but an individual treatment plan was not documented at the time of review on June 28, 2010.
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Plan of Correction
The clinical supervisor will conduct a training with clinical staff on developing and completing treatment plans during the required time frame. This training will take place by September 2, 2010. Documentation for client # 8,9,10,11,12,and 13 can not be completed due to client discharge. Clinical supervisor will be responsible for supervisory follow up and program director will be responsible for oversight. Staff completing treatment plans will do so according to facility policy Clinical Supervisor will be responsible for monitoring the client files on a weekly basis. This will contiune for a period of not less than three months and then it will be done on a quarterly basis. Further monitoring will be conducted via weekly staff supervisions. The Program Director will be responsible for oversight to assure this is being done
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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 six of seven client records.
The findings include:
Thirteen client records were reviewed on June 21, 22 & 28, 2010. Eight of the thirteen records required a treatment plan update. The facility did not document a treatment plan update, as per facility policy, in client records # 1, 2, 3, 4, 5 and 7.
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 updates documented on 5/17/10, 5/28/10 and 6/17/10 did not include an assessment of progress.
In client record #2, the treatment plan updates documented on 5/24/10 and 6/7/10 did not include an assessment of progress.
In client record #3, the treatment plan update documented on 5/4/10 did not include an assessment of progress. Additionally, another treatment plan update was not documented thirty days after the treatment plan updated that was documented on 5/4/10.
In client record #4, the treatment plan updates documented on 5/8/10 and 6/7/10 did not include an assessment of progress.
In client record #5, the treatment plan updates documented on 4/23/10 and 5/24/10 did not include an assessment of progress.
In client record #7, the treatment plan update documented on 2/8/10 did not include an assessment of progress.
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Plan of Correction
The clinical supervisor will conduct a training with clinical staff by September 2, 2010 on developing and completing treatment plan updates. Staff completing treatment plans will do so according to facility policy and Clinical Supervisor will be responsible for monitoring client files on a weekly basis to assure this is being done in a timely fashion. Further monitoring will be conducted via weekly staff supervisions and team meetings. The Program Director will be responsible for oversight to assure this is being done. Clinical Supervisor will monitor completion of an assessment of progress on this treatment plan update and the requirements for completing this form in the required time frame. This documentation for client records #1,2,3,4,5,and 7 can not be completed due to client discharge. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary in three of five client records.
The findings include:
Thirteen client records were reviewed on June 21, 22 & 28, 2010. Five of the thirteen records were identified as discharged and required a discharge summary. The facility did not document a discharge summary, as per facility policy, in client records # 9, 10 and 12.
The facility ' s policy titled " Discharge Summary " states:
" After the client ' s treatment exit when no additional treatment services are anticipated, the counselor shall complete the discharge summary within one week from the discharge. The client's diagnosis, reason for treatment, services received by the client, the client's treatment goals, and assessment of the client's response to treatment and a prognosis for the future shall be included in the report. Upon completion of the summary, the Counselor shall forward it to the Clinical Supervisor for review. As with all forms, it will then be maintained in the client record. A discharge progress note will be written. "
The date of admission for client #9 was 5/18/10 and the discharge date for client #9 was 6/4/10, but a discharge summary was not documented at the time of review on 6/28/10.
The date of admission for client #10 was 5/18/10 and the discharge date for client #10 was 6/11/10, but a discharge summary was not documented at the time of review on 6/28/10.
The date of admission for client #12 was 5/21/10 and the discharge date for client #12 was 6/4/10, but a discharge summary was not documented at the time of review on 6/28/10.
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Plan of Correction
Clinical supervisor will conduct a training by September 2, 2010 on completing a discharge summary within one week from discharge as stated in the facility policy. A discharge summary has been completed for client records # 9,10 and 12. The clinical supervisor will be responsible for supervisory follow up and the program director will be responsible for oversight.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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, the facility failed to document follow-up information in five of six client records.
The findings include:
Thirteen client records were reviewed on June 21, 22 & 28, 2010. Six of the thirteen records were identified as discharged and required follow-up information. The facility did not document follow-up information within seven days after discharge, as per facility policy, in client records # 6, 8, 9, 10 and 12.
The facility ' s policy titled " Follow Up " states:
" 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 directly by the counselor or supervisor ' s designee to determine the client ' s well-being and to maintain the opportunity for re-admission should circumstances warrant it as necessary and appropriate. Information shall be kept in the follow up log binder. "
The discharge date for client #6 was 3/29/10, but follow-up was not documented at the time of review on 6/28/10.
The discharge date for client #8 was 6/4/10, but follow-up was not documented at the time of review on 6/28/10.
The discharge date for client #9 was 6/4/10, but follow-up was not documented at the time of review on 6/28/10.
The discharge date for client #10 was 6/11/10, but follow-up was not documented at the time of review on 6/28/10.
The discharge date for client #12 was 6/4/10, but follow-up was not documented at the time of review on 6/28/10.
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Plan of Correction
The clinical supervisor will conduct a training by September 2, 2010 with clinical and administrative staff on completing required follow up of dischared clients. In addition attempts for follow up will be made and documented in client records #6,8,9,10 and 12 within the next seven days. Staff conducting follow up will do so according to facility policy (within seven days of discharge)and this information shall be kept in a follow up log binder. Clinical Supervisor will be responsible for monitoring the follow up protocol by auditing of discharge client files, as well as the auditing of the follow-up log binder. This will contiune for a period of not less than three months and then it will be done on a quarterly basis. Further monitoring will be conducted via weekly staff supervisions. The Program Director will be responsible for oversight to assure this is being done. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum client capacity.
The findings include:
A Physical plan inspection was conducted on June 22, 2010 at approximately 3:00 PM. The facility ' s authorized maximum capacity for Inpatient Non-Hospital clients is 32. The total number of beds observed during the physical plan inspection was 36. There were 11 beds on the 2nd floor and 25 beds on the 8th floor. The facility is licensed for 9 beds on the 2nd floor and 23 beds on the 8th floor.
The facility did not notify the Department of this change in the client capacity.
An interview with the facility director was conducted on June 28, 2010. The facility director confirmed that the total number of beds was greater than the authorized maximum client capacity. The facility director also confirmed that they did not notify the Department of the change in capacity.
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Plan of Correction
The facility will have the required number of authorized maximum capacity for Inpatient Non-Hospital clients by August 23, 2010. The total number by this date will be 32. There will be 9 beds on the 2nd floor and 23 beds on the 8th floor. |