INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 17-18, 2010 licensure renewal inspection. The follow-up inspection was conducted on November 19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 December 23, 2010.
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Plan of Correction
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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
At the time of the follow-up review on November 19, 2010, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the facility ' s 2010 training year still in progress, and 12 clock hours of annual training for each clinical supervisor is not yet due to be completed. The facility must resubmit original plan of correction.
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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 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
At the time of the follow-up review on November 19, 2010, it was not possible for the licensing specialist to determine if the facility followed the original plan of correction and was in compliance due to the fact that the facility ' s 2010 training year still in progress, and 25 clock hours of annual training for each counselor is not yet due to be completed. The facility must resubmit original plan of correction.
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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 Supervisor(s) to ensure alll trainings are schedule, attended, and documented (feedback) forms within the required time frames to ensure compliance with this regulation. Copies of certificates will be archived in binders. |
709.92(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 interviews with the facility and division directors, the facility failed to document a treatment plan in six of nine client records.
The findings include:
Nine client records were reviewed on November 19, 2010 for documentation of a treatment plan. The facility did not document a treatment plan within thirty 30 days, as per facility policy, in client records # 2, 3, 4, 5, 8 and 9.
An interview with the division director was conducted on November 19, 2010. The division director stated that the facility ' s Treatment Plan policy was revised, and Treatment Plans must be documented within thirty days of admission. The facility ' s previous policy required treatment plans to be documented by the third session.
Client #2 was admitted on 8/4/10, but the treatment plan was documented 10/5/10.
Client #3 was admitted on 9/16/10, but the treatment plan was documented 10/20/10.
Client #4 was admitted on 8/6/10, but the treatment plan was documented 9/17/10.
Client #5 was admitted on 7/6/10, but the treatment plan was documented 9/17/10.
Client #8 was admitted on 7/8/10, but at the time of review on 11/22/10 the treatment plan was not signed or dated.
Client #9 was admitted on 9/7/10, but the treatment plan was documented 11/1/10.
An interview with the facility director on November 19, 2010 confirmed that the treatment plans in the identified client records were not documented within thirty days of admission.
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Plan of Correction
An in-service was held on December 21, 2010 by Program/Clinical Supervisor(s) to address Preliminar/Comprehensive treatment plans and the timeframe in which the plans are due. Going forward Supervisor(s) and/or Director will monitor clinical charts daily to ensure that the clinical staff is utilizing information provided in recent training for treatment plans. Clinical charts will be monitor to ensure that all treatment plans reflect the time frame that is indicated in the policy. Treatment plans will be done within 30 days as provided by agency. |
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 in interview with the facility director, the facility failed to document a treatment plan update in four of five client records.
The findings include:
Five client records were reviewed on November 19, 2010 for documentation of a treatment plan update. The facility did not document a treatment plan update, as per facility policy, in client records # 4, 5, 6 and 7.
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 # 4, the treatment plan update documented on 10/10/10 did not include an assessment of progress.
In client record # 5, the treatment plan was documented on 9/17/10, but a treatment plan update was not documented at the time of review on 11/22/10.
In client record # 6, the treatment plan update documented on 10/7/10 did not include an assessment of progress.
In client record # 7, the treatment plan updates documented on 9/29/10 and 10/25/10 did not include an assessment of progress.
An interview with the facility director on November 19, 2010 confirmed that the treatment plan updates s in the identified client records did not include and assessment of progress.
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Plan of Correction
A in-service was conducted on December 21, 2010 by Program/Clinical Supervisor(s) to address treatment plans and the time frame treatment plans are due in clinical charts. Going forward the Director and/or supervisor(s) will conduct an audit daily to monitor all clinical charts to ensure that the clinical staff is following the policy & procedures that are in place by the agency. Charts will be monitor to ensure that updates are presented every 60 days as required by licensures and according to the policy. |
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 an interview with the facility director, the facility failed to document a case consultation in four of six client records.
The findings include:
Six client records were reviewed on November 19, 2010 for documentation of a case consultation. The facility did not document a case consultation every ninety days, as per facility policy, in client records # 2, 4, 6 and 7.
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 # 2 was admitted to the program on 8/4/10, but the record did not contain a case consultation at the time of review on 11/22/10.
Client # 4 was admitted to the program on 8/6/10, but the record did not contain a case consultation at the time of review on 11/22/10.
Client # 6 was admitted to the program on 8/9/10, but the record did not contain a case consultation at the time of review on 11/22/10.
Client # 7 was admitted to the program on 8/2/10, but the record did not contain a case consultation at the time of review on 11/22/10.
An interview with the facility director on November 19, 2010 confirmed that case consultations were not documented in the identified client records.
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Plan of Correction
On December 14, 2010 in-service was conducted by Director/Clincal Supervisor(s) to review case consultations and the time frame that consultations are due in clinical charts. Going forward Case Consultations will be done in the 90 day time frame indicated in the agency policy. Superviosrs and/or Director will monitor clinical staff and charts closely to assure that case consultations are done as required within the ninety days as indicted in the policy. |