INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 27-28, 2010 licensure renewal inspection. The follow-up inspection was conducted on November 17-18, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 December 22, 2010.
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Plan of Correction
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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
At the time of follow-up review, on November 17-18, 2010, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance. The annual training requirements were not yet due to be completed because the training year is still underway. The facility must resubmit their original plan of correction.
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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. |
705.5 (f) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(f) A bedroom may not be used as a means of egress from or access to another part of the facility.
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Observations
Based upon an observation and an interview, both occurring on on 11/18/2010, the facility failed to ensure that bedrooms were not used as a means to access another part of the facility.
Findings include:
On November 18, 2010 it was observed that the facility had three bedrooms with three beds each. One bedroom had a private bathroom and two bedrooms shared a bathroom that was originally accessible from each bedroom. On November 18, 2010 it was observed that the facility had three male clients in the bathroom that was equipped with its own bathroom, and three male clients in one rooms and three female clients in the other room that had the shared barroom. While the doors were operable from each of the bedrooms to gain access to the shared bathroom, the facility put a shelving unit approximately four feet high in the bathroom to block access from the male room side should the men open the door. The men occupying that room that was originally equipped with a shard bathroom were then required to travel down the corridor and through the other bedroom to access a bathroom.
In addition the facility had set up another bedroom that did not have a bathroom with the intention that the clients would access and use a bathroom located in one of the other bedrooms.
During an interview, the facility director confirmed that the newly created bedroom would have required clients to go through another bedroom to access a bathroom. In addition, the facility director confirmed that the failure to locate the women in the bedroom equipped with a private bathroom created a scenario where a bedroom that originally provided access to its own bathroom, now required clients to use another bathroom thus requiring the clients to travel down the corridor and go through another bedroom to access a bathroom.
The facility director also acknowledged that the facility would not be granted a capacity increase for the additional two beds that they had recently set up and that they beds were required to be removed.
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Plan of Correction
The facility acknowledges that capacity increase would not be granted. In reference to the other three bedrooms the following steps have been taken to correct the deficiency. The shelving unit has been removed from the bathroom ajoining rooms 202 and 204. Each room has its own bathrrom door. There are locks on both bathroom doors to ensure privacy while they are being used. Room 206 has it own bathroom inside the room that is only used by the clients sleeping in that room. All bed rooms will remain gender specific. The Program Supervisor is responsible for implementation and Program Director is responsible for oversight of this practice. |
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 six of eleven client records.
The findings include:
Eleven client records were reviewed on November 17, 2010 for 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 and 6.
The release forms disclosing information to a family member in client records # 1, 2, 3, 4, 5 and 6 did not include a statement informing the client of his/her right to verbally revoke the consent releasing information. The facility documented that the client must revoke the consent in writing.
The release forms disclosing information to a funding source in client records # 1, 2, 3, 4, 5 and 6 did not include a statement informing the client of his/her right to verbally revoke the consent releasing information. The facility documented that the client must revoke the consent in writing.
An interview with the facility director on November 17, 2010 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. 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 five of eleven client records.
The findings include:
Eleven client records were reviewed on November 17, 2010 for psychosocial evaluations. The facility did not document a psychosocial evaluation within 5 days, as per facility policy, in client records # 3, 6, 7, 8 and 9.
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 #3 was 9/8/10, but the biopsychosocial evaluation was documented on 9/15/10.
The admission date for client #6 was 9/14/10, but the biopsychosocial evaluation was documented on 9/24/10.
The admission date for client #7 was 10/25/10, but the biopsychosocial evaluation was documented on 11/2/10.
The admission date for client #8 was 10/12/10, but the biopsychosocial evaluation was documented on 10/18/10.
The admission date for client #9 was 9/24/10, but the biopsychosocial evaluation was documented on 9/30/10.
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Plan of Correction
TheProgram Director will continue to train appropriate staff on completing the psychosocial evaluation within 3-5 days of the client's admission. The clinical supervisor will assure that psychosocial evaluations are being completed in a timely fashion by monitoring staff via weekly supervisory sessions and weekly auditing of client files. Chart audits will continue to be conducted for a period of not less than three months to assure consistency and facility compliance with this standard. Clinical Supervisor will be responsible for ongoing supervisory follow up of clinical staff and Program Director will be responsible for oversight. |
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 four of six client records.
The findings include:
Six client records were reviewed on November 17, 2010 for treatment plan updates. The facility did not document a treatment plan update, as per facility policy, in client records # 2, 3, 5 and 6.
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 #2, the treatment plan updates documented on 9/13/10 and 10/13/10 did not include an assessment of progress.
In client record #3, the treatment plan update documented on 10/13/10 did not include an assessment of progress.
In client record #5, the treatment plan update documented on 9/22/10 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 9/22/10.
In client record #6, the treatment plan update documented on 10/13/10 did not include an assessment of progress.
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Plan of Correction
The Program Director has conducted a training with clinical staff 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. |
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 a review of client records, the facility failed to document follow-up information in seven of seven client records.
The findings include:
Seven client records were reviewed on November 17, 2010 for follow-up information. The facility did not document follow-up information within seven days after discharge, as per facility policy, in client records # 5, 6, 7, 8, 9, 10 and 11.
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 #5 was 11/8/10, but follow-up was not documented at the time of review on 11/17/10.
The discharge date for client #6 was 11/2/10, but follow-up was not documented at the time of review on 11/17/10.
The discharge date for client #7 was 11/5/10, but follow-up was not documented at the time of review on 11/17/10.
The discharge date for client #8 was 11/4/10, but follow-up was not documented at the time of review on 11/17/10.
The discharge date for client #9 was 10/12/10, but follow-up was not documented at the time of review on 11/17/10.
The discharge date for client #10 was 9/29/10, but follow-up was not documented at the time of review on 11/17/10.
The discharge date for client #11 was 9/22/10, but follow-up was not documented at the time of review on 11/17/10.
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Plan of Correction
The Program Director has conducted a training with clinical and administrative staff on completing required follow up of dischared clients. 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 |