INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 30, 2014 through May 1, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document histories that included the client's medical, drug or alcohol, and/or personal history in five of twelve records reviewed. The facility also failed to provide two client records for review.
The findings include:
Twelve client records were reviewed on April 30, 2014 through May 1, 2014, for documentation of the client's medical, drug or alcohol, and/or personal history. The facility failed to document client histories which included medical, drug or alcohol, and/or personal history in client records # 4, 8, 10, 11, and 14. In addition, the facility failed to locate client records # 12 and 13.
Client # 4 was admitted to the program on 1/10/14 and was still an active client as of 5/1/14. The facility failed to document a drug or alcohol, and personal history for client record # 4.
Client # 8 was admitted to the program on 12/16/13 and was still an active client as of 5/1/14. The facility failed to document a drug or alcohol, and personal history for client record # 8.
Client # 10 was admitted to the program on 6/18/13 and was discharged on 11/5/13. The facility failed to document a drug or alcohol, and personal history for client # 10's duration of treatment.
Client # 11 was admitted to the program on 7/24/13 and was discharged on 12/23/13. The facility failed to document a medical, drug or alcohol, and personal history for client # 11's duration of treatment.
Client # 12 was admitted to the program on 5/9/13 and was discharged on 11/9/13. Client # 12's record was requested on 4/30/14. The facility failed to locate client # 12's record as of the completion of the inspection on 5/1/14.
Client # 13 was admitted to the program on 8/5/13 and was discharged on 11/9/13. Client # 13's record was requested on 5/1/14. The facility failed to locate client # 13's record as of the completion of the inspection on 5/1/14.
Client # 14 was admitted to the program on 10/22/13 and was discharged on 2/2/14. The facility failed to document a drug or alcohol, and personal history for client # 14's duration of treatment.
The Director confirmed the findings.
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Plan of Correction
Clinical Supervisor will meet with all clinical staff on 8/1/14 to review the importance of completing the client's medical medical, drug & alcohol and personal history in accordance with established timeline - during the second individual session. This practice is to be reimplemented imediately by the Clinical Supervisor. The Division Director will follow up to ensure this meeting occurs and that this practice is in place. The Clinical Supervisor is also responsible for ongoing monitoring and follow up with random check ups by the Program Director and or Division Director. |
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, the facility failed to document a psychosocial evaluation in five of twelve records reviewed. The facility also failed to provide two client records for review.
The findings include:
Twelve client records requiring documentation of a psychosocial evaluation were reviewed on April 30, 2014 through May 1, 2014. The facility failed to document a psychosocial evaluation in client records # 4, 8, 10, 11 and 14. In addition, the facility failed to locate client records # 12 and 13.
Client # 4 was admitted to the program on 1/10/14 and was still an active client as of 5/1/14. The facility failed to document a psychosocial evaluation for client record # 4.
Client # 8 was admitted to the program on 12/16/13 and was still an active client as of 5/1/14. The facility failed to document a psychosocial evaluation for client record # 8.
Client # 10 was admitted to the program on 6/18/13 and discharged on 11/5/13. The facility failed to document a psychosocial evaluation for client # 10's duration of treatment.
Client # 11 was admitted to the program on 7/24/13 and was discharged on 12/23/13. The facility failed to document a psychosocial evaluation for client # 11's duration of treatment.
Client # 12 was admitted to the program on 5/9/13 and was discharged on 11/9/13. Client # 12's record was requested on 4/30/14. The facility failed to locate client # 12's record as of the completion of the inspection on 5/1/14.
Client # 13 was admitted to the program on 8/5/13 and was discharged on 11/9/13. Client # 13's record was requested on 5/1/14. The facility failed to locate client # 13's record as of the completion of the inspection on 5/1/14.
Client # 14 was admitted to the program on 10/22/13 and was discharged on 2/2/14. The facility failed to document a psychosocial evaluation for client # 14's duration of treatment.
The Director confirmed the findings.
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Plan of Correction
Clinical Supervisor will meet with all staff on 8/1/14 to ensure that charts are only removed from the chart room when the client is on the premises for individual session or as needed by as needed by Administrative or Supervisory Staff. Effective 8/1/14 any chart removed from the chart room must be signed out (to include who signed it out, the date and time as well as time signed back in). This practice will be in effect for both open and closed charts. The Clinical Supervisor will also review the importance of completing the biopsychosocial interview and assessment for every client who enters treatment. This is to be done during the second individual session. The counselors will be told this needs to happen effective immediately. The Division Director will follow up on 8/7/14 (and randomly for the next 6 months) to ensure these practices have been implemented and are being utilized. |
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 a review of client records, the facility failed to document an individual treatment and rehabilitation plan in three of thirteen records reviewed. The facility also failed to provide two client records for review.
The findings include:
Thirteen client records requiring documentation of an individual treatment and rehabilitation plan were reviewed on April 30, 2014 through May 1, 2014. The facility failed to document an individual treatment and rehabilitation plan in client records # 4, 10 and 11. In addition, the facility failed to locate and provide client record # 12 and 13 for review.
Client # 4 was admitted to the program on 1/10/14 and was still an active client as of 5/1/14. The facility failed to document an individual treatment and rehabilitation plan with client # 4.
Client # 10 was admitted to the program on 6/18/13 and was discharged on 11/5/13. The facility failed to document an individual treatment and rehabilitation plan with client # 10 during their duration of treatment.
Client # 11 was admitted to the program on 7/24/13 and was discharged on 12/23/13. The facility failed to document an individual treatment and rehabilitation plan with client # 11 during their duration of treatment.
Client # 12 was admitted to the program on 5/9/13 and was discharged on 11/9/13. Client # 12's record was requested on 4/30/14. The facility failed to locate client # 12's record as of the completion of the inspection on 5/1/14.
Client # 13 was admitted to the program on 8/5/13 and was discharged on 11/9/13. Client # 13's record was requested on 5/1/14. The facility failed to locate client # 13's record as of the completion of the inspection on 5/1/14.
The Director confirmed the findings.
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Plan of Correction
Clinical Supervisor will meet with clinical staff 8/1/14, she will also review the established protocol for treatment planning. Initial Treatment Plans are due on the day of admission to treatment, the Comprehensive Treatment Plan is due within 30 days of admission and updates are due every 30 days (for IOP) and 60 days (for OP). Clinical Supervisor will review all closed charts every month and 20% (randomly selected) open charts to ensure that initial, comprehentive and updated treatment plans are being completed as required. All clinicians who have not yet attended, will be scheduled to attend the newly revised Record Keeping and Clinical Standards training. Division Director will be responsible to ensure that clinicians continue to meet these standards on an ongoing basis. |
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 a review of client records, the facility failed to document a treatment and rehabilitation plan update at least every 60 days in five of twelve records reviewed. The facility also failed to provide two client records for review.
The findings include:
Twelve client records requiring documentation of a treatment and rehabilitation plan update every 60 days were reviewed from April 30, 2014 through May 1, 2014. The facility failed to document a treatment and rehabilitation update in client records # 8, 9, 10, 11 and 14. In addition, the facility failed to locate and produce client records # 12 and 13 for review.
Client # 8 was admitted to the program on 12/16/13 and was still an active client as of 5/1/14. The facility documented the individual treatment plan on 12/27/13. The facility failed to document treatment plan updates by 2/27/14 and 4/27/14.
Client # 9 was admitted to the program on 4/19/13 and was discharged on 10/16/13. The facility documented the individual treatment plan on 5/7/13. The facility failed to document treatment plan updates by 7/7/13 and 9/7/13.
Client # 10 was admitted to the program on 6/18/13 and was discharged on 11/15/13. The facility failed to document any treatment plan updates for client # 10's duration of treatment.
Client # 11 was admitted to the program on 7/24/13 and was discharged on 12/23/13. The facility failed to document a treatment plan update for client # 11's duration of treatment.
Client # 12 was admitted to the program on 5/9/13 and was discharged on 11/9/13. Client # 12's record was requested on 4/30/14. The facility failed to locate client # 12's record as of the completion of the inspection on 5/1/14.
Client # 13 was admitted to the program on 8/5/13 and was discharged on 11/9/13. Client # 13's record was requested on 5/1/14. The facility failed to locate client # 13's record as of the completion of the inspection on 5/1/14.
Client # 14 was admitted to the program on 10/22/13 and was discharged on 2/2/14. The facility documented the individual treatment plan on 10/22/13. The facility failed to document a treatment plan update by 12/22/13.
The Director confirmed the findings.
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Plan of Correction
Clinical Supervisor will meet with clinical staff on 8/1/14. She will address the need for training plans to be done every 30 days for 1B level of care and at least every 60 days for 1A level of care. Clinical Supervisor will be responsible for ongoing superision of charts to ensure that treatment plans are completed within required timeframes. The Division Director will monitor this process.
It is unacceptable to misplace clinical charts. To ensure that charts are able to be located at all times, the following plan has been developed and is to be implemented effective 8/1/14. Clinical Supervisor will meet with all staff on 8/1/14 to ensure that charts are only removed from the chart room when the client is on the premises for individual session or as needed by as needed by Administrative or Supervisory Staff. Effective 8/1/14 any chart removed from the chart room must be signed out (to include who signed it out, the date and time as well as time signed back in). The Administrative Coordinator will ensure that all charts have been signed back in by the close of business each day. The Division Director will follow up on 8/7/14 (and randomly for the next 6 months) to ensure this practice has been implemented and is being utilized. This practice will be in effect for both open and closed charts. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment plan in seven of ten records reviewed.
The findings include:
Ten client records were reviewed from April 30, 2014 through May 1, 2014 to assure that counseling services were provided according to the individual treatment and rehabilitation plan. The facility failed to assure that counseling was provided in accordance with the treatment and rehabilitation in seven out of ten records reviewed, client record # 1, 2, 3, 6, 7, 8 and 9.
Client # 1 was admitted to the program on 11/25/13 and was still an active client as of 5/1/14. The individual treatment plan that was completed on 12/9/13 prescribed individual sessions once a week and group sessions four times a week. The facility failed to follow the prescribed treatment plan as the record only included documentation of the following treatment services: Individual sessions - 12/9/13, 12/30/13, and 2/26/14; and Group sessions - 12/10/13, 12/11/13, 12/12/13, 12/16/13, and 12/19/13. 12/23/13, 12/26/13, 12/30/13, 12/31/13 and 3/18/14.
Client # 2 was admitted to the program on 12/6/13 and was still an active client as of 5/1/14. The individual treatment plan that was completed on 12/6/13 prescribed individual sessions once a week and group sessions twice a week. The facility failed to follow the prescribed treatment plan as the record only included documentation of the following treatment services: Individual sessions - 12/6/13, 1/6/14, 1/14/14, 2/12/14, and 2/19/14; and Group sessions - 12/11/13, 12/18/13, 12/26/13, 1/3/14, 1/9/14, 1/29/14, 2/3/14, 2/10/14, 3/3/14 and 3/5/14.
Client # 3 was admitted to the program on 3/18/14 and was still an active client as of 5/1/14. The individual treatment plan that was completed on 3/18/14 prescribed individual sessions once a week and group sessions three times a week. The facility failed to follow the prescribed treatment plan as the record only included documentation of the following treatment services: Individual sessions - 3/18/14; and Group sessions - 3/21/14.
Client # 6 was admitted to the program on 3/25/14 and was still an active client as of 5/1/14. The individual treatment plan that was completed on 3/25/14 prescribed individual sessions once a week and group sessions three times a week. The facility failed to follow the prescribed treatment plan as the record only included documentation of the following treatment services: Individual sessions - 3/28/14; and Group sessions - none.
Client # 7 was admitted to the program on 10/17/13 and was still an active client as of 5/1/14. The individual treatment plan that was completed on 10/17/13 prescribed individual sessions once a week. The facility failed to follow the prescribed treatment plan as the record only included documentation of the following treatment services: Individual sessions - none; and Group sessions - 11/1/13, 11/4/13, 11/6/13, 11/8/13, 11/12/13, 11/13/13, 11/18/13, 11/20/13, 11/22/13 and 2/6/14.
Client # 8 was admitted to the program on 12/16/13 and was still an active client as of 5/1/14. The individual treatment plan that was completed on 12/27/13 prescribed individual sessions once a week and group sessions twice a week. The facility failed to follow the prescribed treatment plan as the record only included documentation of the following treatment services: Individual sessions - 12/27/13 and 1/21/14; and Group sessions -12/30/13, 12/31/13, 1/3/14, 1/6/14, 1/8/14, 1/10/14, 1/15/14, 1/21/14, 1/27/14, 2/5/14 and 2/12/14.
Client # 9 was admitted to the program on 4/19/13 and was discharged on 10/16/13. The individual treatment plan that was completed on 5/7/13 prescribed individual sessions once a week and group sessions three times a week. The facility failed to follow the prescribed treatment plan as the record only included documentation of the following treatment services: Individual sessions - 6/28/13, 7/31/13, 8/16/13 and 9/20/13; and Group sessions - 6/10/13.
The Director confirmed the findings.
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Plan of Correction
This is another topic that will be added to the in-service training/meeting that will be held with clinical staff by the Division Director by 6/18/14. It will be reviewed that the frequency of treatment documented on the treatment plan must acurately reflect the number of services attended by the individual. Or, there should be a "no session" or "collateral" note explaining why the individual did not attend treatment as scheduled. The Clinical/Program Supervisor will follow up with ongoing chart audits for compliance in this area. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to ensure that counseling was provided on a regular and scheduled basis in two of two client records reviewed. The facility also failed to provide 2 client records for review.
The findings include:
Two client records were reviewed from April 30, 2014 through May 1, 2014 to ensure that counseling was provided on a regular and scheduled basis. The facility failed to ensure that counseling was provided on a regular and scheduled basis in client record # 11 and 15. In addition, the facility failed to locate and provide client records # 12 and 13 for review.
Client # 11 was admitted to the program on 7/24/13 and was discharged on 12/23/13. The facility failed to provide documentation that counseling was provided on a regular and scheduled basis. Client record # 11 did not contain documentation to verify that counseling was provided.
Client # 12 was admitted to the program on 5/9/13 and was discharged on 11/9/13. Client # 12's record was requested on 4/30/14. The facility failed to locate client # 12's record as of the completion of the inspection on 5/1/14.
Client # 13 was admitted to the program on 8/5/13 and was discharged on 11/9/13. Client # 13's record was requested on 5/1/14. The facility failed to locate client # 13's record as of the completion of the inspection on 5/1/14.
Client # 15 was admitted to the program on 8/15/13 and was discharged on 10/15/13. The facility failed to provide documentation that counseling was provided on a regular and scheduled basis. Client record # 15 did not contain documentation to verify that counseling was provided; however, two progress notes were provided after the record was reviewed.
The Facility Director confirmed the findings.
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Plan of Correction
The Clinical Supervisor will meet with The Administrative Coordinator and the Administrative Assistant on 8/7/14 to review the importance of filing all notes from the previous week on a weekly basis. The Clinical Supervisor will ensure that she has collected and reviewed all notes that were due for the week and submit to the Administrators for filing weekly. This process is to be implemented effective 8/7/14. The Division Director will monitor this process to ensure compliance.
It is unacceptable to misplace clinical charts. To ensure that charts are able to be located at all times, the following plan has been developed and is to be implemented effective 8/1/14. Clinical Supervisor will meet with all staff on 8/1/14 to ensure that charts are only removed from the chart room when the client is on the premises for individual session or as needed by as needed by Administrative or Supervisory Staff. Effective 8/1/14 any chart removed from the chart room must be signed out (to include who signed it out, the date and time as well as time signed back in). The Administrative Coordinator will ensure that all charts have been signed back in by the close of business each day. The Division Director will follow up on 8/7/14 (and randomly for the next 6 months) to ensure this practice has been implemented and is being utilized. This practice will be in effect for both open and closed charts. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in thirteen out of fifteen records reviewed.
The findings include:
Fifteen client records were reviewed from April 30, 2014 through May 1, 2014. The facility failed to document a complete client record which included a record of services provided, case consultation notes, and/or a discharge summary, in client record # 1, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15.
Client # 1 was admitted to the program on 11/25/13 and was still an active client as of 5/1/14. The facility failed to document a complete client record which included a record of services provided for client # 1.
Client # 3 was admitted to the program on 3/18/14 and was still an active client as of 5/1/14. The facility failed to document a complete client record which included a record of services provided and a case consultation note for client # 3.
Client # 4 was admitted to the program on 1/10/14 and was still an active client as of 5/1/14. The facility failed to document a complete client record which included a record of services provided for client # 4.
Client # 6 was admitted to the program on 3/25/14 and was still an active client as of 5/1/14. The facility failed to document a complete client record which included a record of services provided for client # 6.
Client # 7 was admitted to the program on 10/17/13 and was still an active client as of 5/1/14. The facility failed to document a complete client record which included a record of services provided for client # 7.
Client # 8 was admitted to the program on 12/16/13 and was still an active client as of 5/1/14. The facility failed to document a complete client record which included a record of services provided and a case consultation note for client # 8.
Client # 9 was admitted to the program on 4/19/13 and was discharged on 10/16/13. The facility failed to document a complete client record which included a record of services provided and a case consultation note for client # 9.
Client # 10 was admitted to the program on 6/18/13 and was discharged on 11/5/13. The facility failed to document a complete client record which included a record of services provided, a case consultation note, and a discharge summary for client # 10.
Client # 11 was admitted to the program on 7/24/13 and was discharged on 12/23/13. The facility failed to document a complete client record which included a record of services provided, a case consultation note, and a discharge summary for client # 11.
Client # 12 was admitted to the program on 5/9/13 and was discharged on 11/9/13. Client # 12's record was requested on 4/30/14. The facility was not able to locate client # 12's record as of the completion of the inspection on 5/1/14.
Client # 13 was admitted to the program on 8/5/13 and was discharged on 11/9/13. Client # 13's record was requested on 5/1/14. The facility was not able to locate client # 13's record as of the completion of the inspection on 5/1/14.
Client # 14 was admitted to the program on 10/22/13 and was discharged on 2/2/14.The facility failed to document a complete client record which included a case consultation for client # 14.
Client # 15 was admitted to the program on 8/15/13 and was discharged on 10/15/13. The facility failed to document a complete client record which included a record of services provided.
The Facility Director confirmed the findings.
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Plan of Correction
The Clinical Supervisor will meet with staff on 8/7/14 and will review the paperwork required for a complete chart. All closed charts from the previous month will be reviewed by the second week of the following month. Open charts will be reviewed during the first week of each month with 20% of each caseload being reviewed. Any charts without required documentation will be returned to the clinician for completion and returned to the Clinical Supervisor by the end of the week. The Division Director will monitor this process for compliance. |