INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17-18, 2010 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 and a plan of correction is due on June 19, 2010.
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Plan of Correction
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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 training records, facility policies and procedures and an interview with the facility director, the facility failed to provide documentation of TB/STD training in one of five personnel training records as per facility policies and procedures.
The findings include:
Facility policy titled, Standard: 704.11.c Subject: General Training dated January, 2009 stated:
Core staff training shall be completed within the first three months of employment and
include, but not be limited to:
DOC - Orientation - first 40 hours as per American Corrections Association standards
HIV/AIDS - 6 hours for counselors orientation period
TB/STDS - 4 hours for counselors within three months of employment and other staff
within two years
Fire Safety - [do a preliminary review the first week]
CPR - orientation period
Five personnel training records were reviewed on May 18, 2010. All five personnel training records were required to have documentation of TB/STD and HIV/AIDS training per facility policy. The facility did not provide documentation of TB/STD training in personnel training record # 5.
Employee #5 is a counselor and was hired on January 28, 2008. TB/STD training was due to be completed no later than January 28, 2009. As of the date of inspection the facility did not provide documentation of TB/STD training for employee #5.
An interview with the facility director on May 18, 2010 confirmed that employee #5 did not have documentation of TB/STD training.
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Plan of Correction
Employee number 5 is scheduled to meet the general training requirements for tuberculosis/sexually transmitted diseases for the upcoming training in September 2010. Documentation of the training will be monitor and available for review by Director. Moving forward the Director/Clinical Supervisor will ensure that all staff and newly hired employees meet the reuirements of the required trainings for HIV/AIDS at least 6 hours and TB/STD'S for at least 4 hours of training within the time frame provided in the agency policy. |
704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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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 12 clock hours of training annually for each clinical supervisor in one of two records.
The findings include:
Five personnel training records were reviewed on May 7, 2010. Of the five records reviewed, two were clinical supervisors and required at least 12 clock hours of training for the 2009 training year. The facility did not document at least 12 hours of training for personnel # 4. The training record for personnel # 4 contained 0 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 0 hours of training had been documented for personnel # 4.
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Plan of Correction
Clinical Supervisor(s); employee number #4 is schedule to complete the required 12 clock hours of training annually for year 2010. Documentation of trainings will be monitored by Program Director to ensure all trainings are scheduled, attended, and documented (feedback forms) within the required time frames to ensure compliance with this regulation. Copies of certificates will be archived in binders. |
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:
Five personnel training records were reviewed on May 7, 2010. Of the five records reviewed, one was a counselor and required at least 25 clock hours of training for the 2009 training year. The facility did not document at least 25 hours of training for personnel # 5. The training record for personnel # 5 contained 0 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 0 hours of training had been documented for personnel #5.
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Plan of Correction
Employee number 5 is schedule to complete the required 25 clock hours of training annually for year 2010. Documentation of trainings will be monitored by Program Director and Clinical Supervisor to ensure all trainings are scheduled, attended, and documented (feedback) forms within the required time frames to ensure compliance with this regulation. Copies of certificates will be archived in binders. |
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 the review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation in six of twelve client records.
The findings include:
Twelve client records were reviewed on May 17-18, 2010. All twelve records required documentation of a psychosocial evaluation. The facility did not document a psychosocial evaluation within the first three sessions of the client ' s admission, as per facility policy, in client records # 1, 3, 4, 5, 6 and 8.
The facility ' s policy titled " DELIVERY OF REHABILITATION CLINICAL PROCESSES & PROCEDURES - BIOPSYCHOSOCIAL " states:
"The biopsychosocial, with accompanying assessment and diagnostic summary must be completed within the first three sessions of the client's admission."
Client record #1 contained progress notes to document individual sessions on 1/4/10, 1/21/10, 1/28/10, 2/4/10, 3/10/10, 4/7/10 and 5/5/10, but the record did not contain a biopsychosocial at the time of review on 5/18/10.
Client record #3 contained progress notes to document individual sessions on 12/18/09, 12/31/09 and 1/21/10, but the biopsychosocial was documented on 1/28/10.
Client record #4 contained progress notes to document individual sessions on 12/31/09, 1/7/10, 1/12/10 and 1/26/10, but the biopsychosocial was documented on 2/4/10.
Client record #5 contained progress notes to document individual sessions on 12/29/09, 1/4/10 and 1/25/10, but the biopsychosocial was documented on 2/1/10.
Client record #6 contained progress notes to document individual sessions on 12/29/09, 1/5/10, 1/12/10, 1/19/10 and 1/26/10, but the biopsychosocial was documented on 2/2/10.
Client record #8 contained progress notes to document individual sessions on 1/8/10, 1/28/10, 2/2/10 and 2/12/10, but the biopsychosocial was documented on 2/17/10.
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Plan of Correction
Program Director and Clinical Supervisor will conduct a meeting to review policies and procedures of clinical documentation that is required by the agency. Going forward the Program Director and Clinical supervisor will monitor clinical charts to ensure that the counselor are following the policy title "Delivery of Rehabilitation Clinical Process and Procedures-BioPsychosocial." All charts will be audit following the first three sessions to ensure that the counselor has completed documentation as stated in the policy provided by the agency. |
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 the review of client records and the facility's policies and procedures, the facility failed to document a treatment plan in six of twelve client records.
The findings include:
Twelve client records were reviewed on May 17-18, 2010. All twelve records required documentation of a treatment plan. The facility did not document a treatment plan by the third sessions, as per facility policy, in client records # 1, 4, 5, 6, 10 and 11.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
"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, by the third session (outpatient)."
Client record #1 contained progress notes to document individual sessions on 1/4/10, 1/21/10, 1/28/10, 2/4/10, 3/10/10, 4/7/10 and 5/5/10, but the record did not contain a treatment plan at the time of review on 5/18/10.
Client record #4 contained progress notes to document individual sessions on 12/31/09, 1/7/10 and 1/12/10, but the treatment plan was documented on 1/26/10.
Client record #5 contained progress notes to document individual sessions on 12/29/09, 1/4/10, 1/25/10, 2/1/10 and 2/8/10 but the treatment plan was documented on 2/9/10.
Client record #6 contained progress notes to document individual sessions on 12/29/09, 1/5/10, 1/12/10, 1/19/10, 1/26/10, 2/2/10, and 2/9/10 but the treatment plan was documented on 2/16/10.
Client record #10 contained progress notes to document individual sessions on 11/4/09, 11/6/09, 11/9/09, 11/17/09, 11/24/09 and 12/1/09, but the treatment plan was documented on 12/2/09.
Client record #11 contained progress notes to document individual sessions on 9/30/09, 10/6/09, 10/21/09 and 11/25/09, but the treatment plan was documented on 12/01/09.
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Plan of Correction
The facility policy has been changed to reflect that the treatment plans will be completed within 30 days of admission to the program. Going forward the Director & Clincal Supervisor will monitor all clincal charts to ensure that treatment plans reflect the time frame indicated on facility policy; all treatment plans will reflect signatures by Client, Primary Counselor, Clinical Supervisor and Physician (where applicable) and placed in the client's files. The Director and Clincal Supervisor will ensure that the clincal staff make notations of the treatment plan is noted in progress note for the day of services by the time frame within thirty days. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and the facility's policies and procedures, the facility failed to document a treatment plan to include type and frequency of treatment and rehabilitation services in six of twelve client records.
The findings include:
Twelve client records were reviewed on May 17-18, 2010. All twelve records required documentation of type and frequency of treatment and rehabilitation services. The facility did not document a treatment plan to include type and frequency of treatment services, as per facility policy, in client records # 1, 2, 4, 5, 7 and 8.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" Included in the action plan will be a statement of the type (individual / group / family therapy, health education, etc.) and frequency (daily, 2-3 x weekly, once, ongoing, etc.) of service in which the client will be involved. "
Client record # 1 did not contain a treatment plan at the time of review on 5/18/10.
In client record # 2, the treatment plan documented on 2/25/10 did not include type and frequency of treatment and rehabilitation services.
In client record # 4, the treatment plan documented on 1/26/10 did not include type and frequency of treatment and rehabilitation services.
In client record # 5, the treatment plan documented on 2/9/10 did not include type and frequency of treatment and rehabilitation services.
In client record # 7, the treatment plan documented on 2/4/10 did not include type and frequency of treatment and rehabilitation services.
In client record # 8, the treatment plan documented on 2/2/10 did not include type and frequency of treatment and rehabilitation services.
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Plan of Correction
Going forward the Program Director and Clincal Supervisor will monitor clinical charts to ensure that the treatment plans according to the agengy policy are meeting the regulations. Clinical charts will be audit daily to ensure that clinical staff (counselors) are documenting the frequencies of treatment ( 1x weekly IND/Group session, ongoing, daily and/or etc). |
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 the review of client records and the facility's policies and procedures, the facility failed to document a treatment plan to include a proposed type of support service in eight of twelve client records.
The findings include:
Twelve client records were reviewed on May 17-18, 2010. All twelve records required documentation of a proposed type of support service. The facility did not document a proposed type of support service, as per facility policy, in client records # 1, 3, 4, 5, 6, 8, 10 and 12.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
" The action plan will address the other support services in which the client is to participate including, but not limited to: medical, psychiatric, or psychological service, legal or economic assistance and Double Trouble and/or 12-step meeting attendance. "
Client record # 1 did not contain a treatment plan at the time of review on 5/18/10.
In client record # 3, the treatment plan documented on 1/21/10 did not include support services.
In client record # 4, the treatment plan documented on 1/26/10 did not include support services.
In client record # 5, the treatment plan documented on 2/9/10 did not include support services.
In client record # 6, the treatment plan documented on 2/16/10 did not include support services.
In client record # 8, the treatment plan documented on 2/2/10 did not include support services.
In client record # 10, the treatment plan documented on 12/2/10 did not include support services.
In client record # 12, the treatment plan documented on 10/28/09 did not include support services.
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Plan of Correction
Going forward the Program Director and Clinical Supervisor will monitor clinical charts to ensure that counselors are following policy titled "Procedure For Individual Treatment & Rehabilitation Plan. Policy will be review with counselor during annual weekly staff meeting to ensure counselor will follow policies & procedure.Program Director & Clinical supervisor will monitor charts to ensure that documentation (treatment plans) has indicated proposed type of supportive services. |
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 the review of client records and the facility's policies and procedures, the facility failed to document a treatment plan update in seven of eleven client records.
The findings include:
Twelve client records were reviewed on May 17-18, 2010. Of the twelve records reviewed, eleven required a treatment plan update. The facility did not document a treatment plan update, as per facility policy, in client records # 2, 4, 5, 7, 8, 11 and 12.
The facility ' s policy titled "TREATMENT & REHABILITATION PLAN" states:
" Gaudenzia, Inc. Outpatient, will ensure treatment and rehabilitation plans will be reviewed and updated at least every sixty days. The treatment plan update will include an assessment of the client ' s progress in relationship to stated goals. "
In client record # 2, the treatment plan update documented on 4/30/10 did not include an assessment of progress.
In client record # 4, the treatment plan update documented on 3/25/10 did not include an assessment of progress.
In client record # 5, the treatment plan update documented on 3/22/10 did not include an assessment of progress.
In client record # 7, the treatment plan update documented on 4/1/10 did not include an assessment of progress.
In client record # 8, the treatment plan was documented on 2/2/10, but a treatment plan update was not documented at the time of review on 5/18/10.
In client record # 11, the treatment plan updates documented on 1/5/10 and 2/26/10 did not include an assessment of progress.
In client record # 12, the treatment plan was documented on 10/28/09, but a treatment plan update was not documented at the time of review on 5/18/10.
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Plan of Correction
During a clinical staff meeting the policy & procedures for treatment plans update was reviewed with clinical staff (counselors). Going forward the Program Director and Clinical Supervisors will audit clincal charts daily to ensure that treatment plan updates are being reviewed and updated at least every sixty days as an required by the agency. The treatment plan updates will include an assessment of clients progress in relations to the goals stated on treatment plan(s). |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records and the facility's policies and procedures, the facility failed to document a case consultation in five of twelve client records.
The findings include:
Twelve client records were reviewed on May 17-18, 2010. All twelve records required a case consultation. The facility did not document a case consultation every ninety days, as per facility policy, in client records # 1, 2, 7, 8 and 12.
The facility ' s policy titled "CASE CONSULTATION" states:
" Each clients progress shall be reviewed on a supervisory, peer review, or multi-disciplinary level at least every ninety (90) days, and when there is a change in the clients treatment or as required by third party payers. "
Client # 1 was admitted to the program on 1/4/10, but the record did not contain a case consultation at the time of review on 5/18/10.
Client # 2 was admitted to the program on 1/7/10, but the record did not contain a case consultation at the time of review on 5/18/10.
Client # 7 was admitted to the program on 1/7/10, but the record did not contain a case consultation at the time of review on 5/18/10.
Client # 8 was admitted to the program on 1/8/10, but the record did not contain a case consultation at the time of review on 5/18/10.
Client # 2 was admitted to the program on 10/19/10 and discharged on 3/24/10, but the record did not contain a case consultation at the time of review on 5/18/10.
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Plan of Correction
Program Director held a staff meeting to address concerns following the audit. During this meeting case consultations policy & procedures was reviewed. Going forward the Program Director & Clinical Supervisor will ensure that case consultations are done at least every ninety days as required according to facility policies & procedures. |