INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Outpatient 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 17, 2009.
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Plan of Correction
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704.8(a) LICENSURE Qualifications-Counselor Assistant
704.8. Qualifications for the position of counselor assistant.
(a) A person who does not meet the educational and experiential qualifications for the position of counselor may be employed as a counselor assistant if the requirements of at least one of the following paragraphs are met. However, a project may not hire more than one counselor assistant for each employee who meets the requirements of clinical supervisor or counselor.
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Observations
Based on a review of administrative documentation, the facility failed to hire no more than one counselor assistant for each employee who meets the requirement of clinical supervisor or counselor.
Findings:
The facility ' s staffing forms were reviewed on May 14, 2009. The facility was required to hire no more than one counselor assistant for each employee who meets the requirement of clinical supervisor or counselor. At the time of the inspection, the facility ' s staff consisted of four full-time counselor assistants, and only one full-time clinical supervisor and two full-time counselors.
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Plan of Correction
Two Counselor Assistants will be promoted to Counselor on 6/2/9 and 8/18/9 respectively. This will correct the existing problem. For the future the Program Supervisor will ensure that the Counselor/Supervisor ratio to Counselor Assistant will comply with the standard. This will be monitored by the Division Director during the interview and hiring process. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to document emergency training in four of five personnel records.
Findings:
Nine personnel records were reviewed on May 14, 2009. Documentation of emergency training, within seven days of the date of hire, was required in five personnel records. The facility did not document emergency training within seven days of hire in personnel records # 5, 6, 7 and 9.
Employee #5 date of hire was 11/24/08, but emergency training was not documented until 3/3/09.
Employee #6 date of hire was 10/20/08, but emergency training was not documented until 10/30/08.
Employee #7 date of hire was 9/2/08, emergency training was not documented at time of inspection.
Employee #9 date of hire was 8/18/08, but emergency training was not documented until 10/17/08.
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Plan of Correction
Emergency training within seven days of hire will be documented on the appropriate form by the Counselor and Program Supervisor. For the future hires failure to do will result in disciplinary action for the Program Supervisor. This plan implemented immediately monitored by Division Director. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to secure all client records within locked storage containers.
Findings:
An inspection of the facility ' s physical plant was conducted on May 14, 2009 at approximately 09:20. Discharged client records were stored in boxes in an unlocked room in the basement. Additionally, the room was not used solely for the purpose of record storage. Other non-record related items were also stored in this room.
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Plan of Correction
Discharge client records are placed in a lock room for removal to archival. A sign will be placed on the door indicating this room may only be accessed by key by the Administrative Coordinator. The room will be checked once weekly by the Administrative Coordinator for compliance to the procedure and monitored by the Program Supervisor.
All stored objects will be removed from this room by the Central Region Facilities Manager as of 6/15/09. This process will be monitored by the 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 three of six client records.
Findings:
Nine client records were reviewed on May 14, 2009. Psychosocial evaluations were reviewed in six client records. The facility did not document a psychosocial evaluation in client records # 1, 2 and 5.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths that can contribute to the resolution of identified problems in client records # 1, 2 and 5.
The facility did not document a psychosocial evaluation to include the client ' s preferred coping mechanisms in client records # 1, 2 and 5.
The facility did not document a psychosocial evaluation to include the potential or available client support systems in client records 1 and 5.
The facility did not document a psychosocial evaluation to include negative factors that might affect treatment in client records 1, 2 and 5.
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Plan of Correction
The Program Supervisor is responisble for training re: psychosocial evaluations on assets/strengths, coping mechanicism, support systems, and negative factors impacting treatment for all clinical personnel. This training will be documented through feedback forms through in-service and reflected on monthly reports. This improvement process will be reviewed by Program Supervisor through clinical meetings held weekly and monthly quality assurance review. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document treatment plans to include proposed types of supportive services in three of six client records.
Findings:
Nine client records were reviewed on May 14, 2009. Treatment plans with proposed types of supportive services were reviewed in six client records. The facility did not document treatment plans to include proposed types of supportive services in client records # 1, 3 and 6.
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Plan of Correction
The Program Supervisor will conduct training re: support services utilized. Training will be documented per policy. Treatment plans will be reviewed by Program Supervisor at time of signature process and returned to Counselor and client for review of this aspect where necessary. |
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 plan update in four of six client records.
Findings:
Nine client records were reviewed on May 14, 2009. A treatment plan update was required in five client records. The facility did not document a treatment plan update at least every sixty days for outpatient client records # 2, 5 and 6.
Additionally, the facility did not document a treatment plan update at least every thirty days for intensive outpatient client record # 3.
Client record #2 admission date 12/8/08; treatment plan documented 12/8/08; treatment plan update documented 4/2/09.
Client record #5 admission date 11/18/08; treatment plan documented 11/18/08; treatment plan updates documented 1/20/09 and 4/14/09.
Client record #6 admission date 9/17/08; treatment plan documented 9/27/08; treatment plan updates documented 10/9/08, 1/15/09 and 3/26/09.
Client record #3 admission date 3/19/09; treatment plan documented 3/19/09; treatment plan update documented 5/1/09.
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Plan of Correction
Timeliness of treatment plans will be reviewed in weekly supervisory session and documented by Program Supervisor in supervisory session notes. On a weekly basis, utilization of the census tool developed to monitor treatment plan timeliness will occur to identify those counselors who need to complete treatment plans and treatment plan updates for the next week. This will be documented in clinical meeting notes. Failure to do so will dictate the appropriate disciplinary action by the Program Supervisor/Division Director. |
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 a review of client records, the facility failed to document follow-up information in two of three client records.
Findings:
Nine client records were reviewed on May 14, 2009. Follow-up information was required in three client records. The facility did not document follow-up information within 30 days after discharge, as stated in the project's policy and procedures manual, in client records # 8 and 9.
Record # 8 was discharged 3/20/09, but follow-up information was not documented at time of inspection.
Record # 9 was discharged 3/3/09, but follow-up information was not documented at time of inspection.
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Plan of Correction
Follow up per policy and procedure will be fully implemented by the Program Supervisor and the Administrative Coordintor. Completion of follow up will be monitored monthly in the Administrative meeting for policy compliance and documented in the minutes. Monitoring of this compliance will be completed by the Division Director. |