INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22 - 23, 2012 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.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision.
The findings include:
On May 7 - 9, 2012, two personnel records were reviewed for the position of clinical supervisor. The facility failed to ensure that two of two employees received the core curriculum training in clinical supervision, specifically employee # 4 and 7.
Employee # 4 was hired on 10/13/10 for the position of clinical supervisor. Employee # 4 has three years of clinical experience and no verifiable prior clinical supervisor experience, thus employee # 4 was required to complete a core curriculum in clinical supervision. At the time of review on May 9, 2012 employee # 4 did not have the core curriculum training in clinical supervision. The findings were disputed; however, there was no documentation to confirm prior clinical supervisor experience.
Employee # 7 was hired on 8/26/10 for the position of clinical supervisor. Employee # 7 has four years of clinical experience and no prior clinical supervisor experience, thus employee # 7 was required to complete a core curriculum in clinical supervision. At the time of review on May 9, 2012 employee # 7 did not have the core curriculum training in clinical supervision.
The Facility Director confirmed the findings.
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Plan of Correction
Human Resource Department will review and screen all employees prior to being hired or promoted to a position without the qualifications or mandatory training required. Administrative staff will provide supervisory follow up through conducting monthly personnel chart audits. Program Director will be responsible for oversight.
Employee # 4 and 7 attended the Core Curriculum training at the Philadelphia location the week of June 11-15, 2012. The training was successfully completed and training certificate obtained. Full compliance wille met July 31, 2012. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in one personnel record reviewed.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1's personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
The findings were reviewed with the human resources staff.
The Project was previously cited for noncompliance with this standard.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees wthin required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all managers during the first week of December. In addition, the Training DEpartment will coordinate with the Executive Assistant to ensure that development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current signed individual Training Plan is presently in the Project Director's file. Individual Training Plans will be completed for all amployees by January 31st, 2013 as per our policy. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and a review of the Staffing Requirements Facility Summary Report, the facility failed to document that all staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training and other health related topics using a Department approved curriculum in one of three employee records.
The findings include:
On May 7 - 9, 2012, three employee records requiring documentation of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training were reviewed. The facility failed to ensure that one of three employees received at least 4 hours of TB/STD training, specifically employee # 8.
Employee # 8, a counselor/intake specialist, was hired 4/11/11. HIV/AIDS and TB/STD training was to have been documented within the first year of employment or by 4/11/12. The facility failed to ensure that employee # 8 received the required 4 hours of TB/STD training.
The facility confirmed the findings.
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Plan of Correction
Program Director and Program Supervisor has scheduled and will conduct a training on required staff trainings and time frame which the trainings must be completed for all staff in addition to completing individual training plans to be followed. Administrative staff will be responsible providing supervisory follow up through monthly personnel file audits. Program Director will be responsible for providing oversight. Employee # 8 has been scheduled for these required trainings to be completed by August 31, 2012. Full compliance will be met by August 31, 2012. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill log, the facility failed to prepare alternate exit routes during fire drills.
The findings include:
On May 23, 2012, fire drill logs were reviewed covering the period from May 2012 - June 2011. The facility failed to document alternate exits during eleven of eleven fire drills. The facility consistently documented on the fire drill log from the period of May 2012 - June 2012 the use of the North Tower.
The Facility Director confirmed the findings.
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Plan of Correction
A training will be conducted by the Program Director and Clinical Supervisor to review the procedure for conducting and documenting evacuation for fire drills. This training will include the need to demonstrate and document alternatiing exits. Program Director will be responsible for monthly supervisory follow up and Division Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2012. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"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)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant policies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis." These policies will be revised and approved by July 31st, 2012.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services by the end of the fiscal year.
The findings include:
On May 7 through May 9, 2012, the project's administrative records were reviewed for a financial audit following the end of their fiscal year. The project's fiscal year runs from July 1 through June 30. The financial audit was to be documented by the end of the fiscal year; the financial audit was documented on February 20, 2012.
Administration confirmed that the financial audit had not been documented following the end of the fiscal year; the financial audit was documented on February 20, 2012.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner." The Financial Audit for Fiscal Year 2011-2012 will be completed within 6 months after the June 30th close of Gaudenzia's fiscal year (by December 31st, 2012) as per Chapter 709.25(a).
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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 a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in three of ten client records.
The findings include:
On May 22 - 23, 2012, ten client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 4 Pa. Code 255.5. The facility failed to adhere to the requirements specified at 4 Pa. Code in three of ten records, specifically client record # 7, 8, and 9.
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Client # 7 was admitted to the program on 1/4/12 and discharged on 3/26/12. A signed "Confidential Request to Release Information" form was documented on 1/4/12 to a funding source. The signed "Confidential Request to Release Information" form documented the release of information which exceeds the limitations of 4 Pa. Code 255.5.
The form documented the release of medical information and all pertinent information.
Client # 8 was admitted to the program on 5/16/12 and discharged on 5/22/12.
The facility did not obtain a valid consent to release confidential information; the facility released to a government agency a form that did not adhere to the requirements specified at 4 Pa. Code 255.5 as it revealed the substance currently being used by client # 8, the frequency, and the daily monetary amount.
Client # 9 was admitted to the program on 5/16/12 and discharged on 5/22/12.
The facility did not obtain a valid consent to release confidential information; the facility released to a government agency a form that did not adhere to the requirements specified at 4 Pa. Code 255.5 as it revealed the substance currently being used by client # 9, the frequency, and the daily monetary amount.
The Program Supervisor confirmed the findings.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will include confidentiality and the restricitions that apply to voluntary consent. These restricitions are limited to the following:
1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
In regard to client # 7,8,9, updated consents could not be completed as they are no longer at the program.
Program Supervisor will be responsible for providing monthly supervisory follow up through monthly chart audits and Program Director will be responsible for ongoing oversight. Full compliance will be met effective July 31, 2012.
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in four of ten client records.
The findings include:
On May 22 - 23, 2012, ten client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 28 Code 709.28 and 42 CFR Part II subpart C subsection 2.31 (b). The facility failed to adhere to the requirements specified at 28 Pa. Code in four of ten records, specifically client record # 2, 6, 7, and 8.
28 Pa. Code 709.28 states:
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:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
Client # 2 was admitted to the program on 1/11/12.
Client # 2 signed two "Confidential Request to Release Information" forms. However, the forms were incomplete and failed to indicate the name of the person, agency or organization to whom disclosure is made, the specific information disclosed, the purpose of disclosure, a dated signature of a witness, and the expiration date of the consent. In addition, two letters written by facility staff to unknown parties were documented in client record # 2 without consent to release.
Client # 6 was admitted to the program on 1/24/12 and discharged on 3/7/12.
A signed "Confidential Request to Release Information" form documented on 1/24/12, to a government agency, failed to indicate what information would be disclosed.
Client # 7 was admitted to the program on 1/4/12 and discharged on 3/26/12.
A signed "Confidential Request to Release Information" form documented on 1/4/12, to a government agency, failed to indicate what information would be disclosed.
Client # 8 was admitted to the program on 5/16/12 and discharged on 5/22/12.
Based on a conversation with facility staff and a review of clinical documentation the client was referred to another facility within the project; however the facility did not document an informed consent to release to the receiving facility. Per conversation, facility staff made copies of client # 8's record, but failed to document an informed consent to release.
The Program Supervisor confirmed the findings.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will focus on the requirements to obtain for each client an informed voluntary consent from the client for the disclosure of information contatined in the client record. Program Supervisor will be responsible for monthly Supervisory follow up through monthly chasrt audits and Program Director will be responsible for ongoing oversight. In regard to client record # 2,6,7,8 updated consents could not be completed as they are no longer in the program. Full compliance will be met July 31, 2012. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual, administrative documentation, and a conversation with nursing staff, the facility failed to document inspection of the storage area according to policy.
Findings:
The facility policy states: "The drug storage area and medications shall be inspected by a registered pharmacist per agreement who comes on site at least monthly. The Medication and Drug Storage Inspection form shall be completed monthly by the pharmacist conducting the inspection and by the nurse who accompanies him/her during the inspection."
On May 24, 2012 a physical plant inspection was conducted at approximately 10:30 AM.
Based on a review administrative documentation and a conversation with nursing staff; the facility did not comply with the policy and procedures manual as the pharmacist does not come on site monthly to inspect storage area, rather the storage area inspection is conducted in house by nursing staff.
The head nurse confirmed the findings.
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Plan of Correction
This policy has been revised in the Gaudenzia Policy and Procedure manual by the Quality Improvement Director and the governing body confirmed the policy change. The policy has been reviewed by necessary staff and states that the inspection of medication storage area will be conducted internally by a qualified health care professional such as a licensed nurse and will be overseen by the Director of Nursing. Full compliance will be met by July 31, 2012. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. 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 a medical history in three of ten records reviewed.
The findings include:
On May 22 -23, 2012, ten records requiring documentation of the client's medical history were reviewed. The facility failed to document a medical history in three of ten records reviewed, specifically client records # 8, 9, and 10.
Client # 8 was admitted to the program on 5/16/12 and discharged on 5/22/12.
Client record # 8 did not include a medical history.
Client # 9 was admitted to the program on 5/16/12 and discharged on 5/22/12.
Client record # 9 did not include a medical history.
Client # 10 was admitted to the program on 3/2/12 and discharged on 3/15/12.
Client record # 10 did not include a medical history.
The Program Supervisor did not dispute the findings.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will focus on the requirement to complete a medical history in accordance with this standard. Program Supervisor will be responsible for monthly supervisory follow through monthly chart audits up and Program Director will be responsible for ongoing oversight. Full compliance will be met July 31, 2012. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document physical examinations within 7 days of admission in six of eight records reviewed.
The findings include:
The facility policy states: "A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Other exceptions are: 1. The client received a complete physical examination no longer than one month prior to admission; that the program staff can obtain the results in writing; and the nurse on duty is able to ascertain no noticeable medical problems."
On May 22 - 23, 2012, eight records requiring documentation of a physical examination were reviewed. The facility failed to document physical examinations within 7 days of admission per policy in six of eight records reviewed, specifically client records # 2, 3, 4, 5, 6, and 7.
Client # 2 was admitted to the program on 1/11/12. The physical exam for client # 1 was dated 2/28/12.
Client # 3 was admitted to the program on 2/24/12. The physical exam for client # 2 was dated 3/15/12.
Client # 4 was admitted to the program on 1/24/12. The physical exam for client # 3 was dated 3/2/12.
Client # 5 was admitted to the program on 11/23/11. The physical exam for client # 5 was dated 12/5/11.
Client # 6 was admitted to the program on 1/24/12. The physical exam for client # 6 was dated 2/15/12.
Client # 7 was admitted to the program on 1/4/12. The physical exam for client # 7 was dated 1/24/12.
The Facility Director confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
Additional services have been obtained by a qualified physician to perform physicals within 7 days of admission except on holiday and weekend. This area of non-compliance has been corrected. As of this date 6/28/2012. Due to this being a repeat citation during the 2011 inspection the following supervisory and follow up steps have been put in place. Clinical Supervisor will be responsible for weekly supervisory follow up. Nursing Director will be responsible for ongoing monthly oversight. This information will also be provided to the Quality Improvement Director to assure that full compliance is maintatined on a program an agency level. |
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 and a review of the facility's policy and procedures manual, the facility failed to document follow-up information in one of four records reviewed.
The findings include:
The facility policy states:
"In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, 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 neither are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note remember to state the reason for the refusal in the note and on the form.
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow up Log binder."
On May 23, 2012, four client records requiring documentation of follow-up information were reviewed. The facility failed to document follow-up information in one of four records reviewed, specifically client record # 6.
Client # 6 was admitted to the program on 1/24/12 and discharged on 3/7/12.
The facility did not document follow-up information at the time of review on 5/23/12.
The Program Supervisor confirmed the findings.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the 2011 and 2010 licensure inspection.
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Plan of Correction
A training has been scheduled and will be conducted by Program Director and Program Supervisor to address documentation. This training will focus on the requirement to document follow up as required by this standard. Program Supervisor will be responsible for conducting weekly supervisory follow up and Program Director will be responsible for conducting ongoing oversight. This supervisory follow-up and ongoing oversight has been increased and will be documented on a follow up log audit form due the this facility being previously cited for noncompliance with this standard during 2011 and 2010 licensure inspection. Full compliance will be met July 31, 2012. |