INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 1, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia Erie Inc / Community House 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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with his/her supervisor to discuss his/her duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
Personnel records were reviewed on November 28-29, 2011. One personnel record reviewed was that of the clinical supervisor. This personnel record required the documentation of monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 2.
Employee # 2 was hired at the project on September 24, 2008 and was promoted to the position of clinical supervisor on December 21, 2010. Monthly supervision meetings were required to take place in January, February, March, April, May and June 2011. There was no documentation of monthly supervision meetings in the personnel record of employee # 2.
An interview with the facility director took place on November 29, 2011 at which time it was confirmed that there was no documentation of monthly supervision meetings.
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Plan of Correction
New Clinical Supervisors, when hired, will receive monthly supervision meetings. These meetings will be documented and placed in their personnel files for their first six months of employment. Division or Program Director will complete these meetings. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document a written job description for the position of facility director, which contained the employee's and supervisor's dated signatures in one of one personnel record.
The findings include:
One personnel record for the facility director was reviewed on December 2, 2011. This record required documentation of a signed job description. The facility did not document a signed job description for the position of facility director in personnel record #9.
Employee #9 is the Director of Finance and Operations and was hired on September 16, 1996. The previous facility director resigned on November 11, 2011. Per the Staffing Requirements Facility Summary Report, employee #9 assumed the duties of facility director as of November 11, 2011. There was no documentation of a signed job description for the position of facility director in personnel record #9.
The facility director was interviewed on December 2, 2011. It was confirmed that there was no signed job description in place which included the duties of facility director.
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Plan of Correction
A signed job description has placed in the "Interim" Facility Directors personnel file. Regional Director along with the Director of Finance & Operations (In charge of HR in Erie) will monitor employee files to ensure correct job descriptions are in the employee files. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 document that counseling services were provided according to the individual treatment and rehabilitation plan in two of five client records.
The findings include:
Five complete client records were reviewed on December 1, 2011. All clients are required to have counseling services provided according to the individual treatment and rehabilitation plan. Counseling services were not provided according to the individual treatment and rehabilitation plan in client records # 4 and 5.
Client #4 was admitted to treatment on May 5, 2011 and discharged on August 3, 2011. The individual treatment and rehabilitation plan dated May 27, 2011 stated that individual treatment sessions are to occur bi-weekly and group sessions are to occur daily. The only individual sessions documented in the client record were on May 23, June 13 and July 13.
Client #5 was admitted to treatment on April 20, 2011 and discharged on July 20, 2011. The individual treatment and rehabilitation plan dated April 29, 2011 stated that individual treatment sessions are to occur bi-weekly and group sessions are to occur daily. The only individual sessions documented in the client record were on April 22, May 6, May 20 and May 27, 2011.
Both client records # 4 and 5 contained a deficiency notification listing the missing documentation. An interview with the clinical supervisor took place on December 1, 2011 at which time it was confirmed that the aforementioned client records were missing the required documentation. It was reported that the counselors who were maintaining these client records are no longer employed at the facility.
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Plan of Correction
Program Supervisor will conduct training by 1/27/12 on agency's policies on time frames and completions of agency paperwork. Program Supervisor will monitor monthly during UR/QI meetings. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete chronological listing of the various specific services provided to each individual client in two of five client records.
The findings include:
Five complete client records were reviewed on December 1, 2011. All five client records required the completion of a record of services provided. The record of services provided was incomplete in client records #4 and 5.
Client #4 was admitted to treatment on May 5, 2011 and discharged on August 3, 2011. Progress notes were completed for individual sessions occurring on 5/23/11, 6/13/11 and 7/13/11 as well as group sessions occurring on 5/23/11, 5/26/11, 6/7/11, 6/13/11, 7/4/11, 7/21/11 and 7/25/11, however, none of these sessions were documented on the record of services.
Client #5 was admitted to treatment on April 20, 2011 and discharged on July 20, 2011. Progress notes were completed for group sessions on 5/23/11, 5/26/11, 6/7/11, 6/13/11 and 7/4/11, however, none of these sessions were documented on the record of services.
Both client records # 4 and 5 contained a deficiency notification listing the missing documentation. An interview with the clinical supervisor took place on December 1, 2011 at which time it was confirmed that the aforementioned client records were missing the required documentation. It was reported that the counselors who were maintaining these client records are no longer employed at the facility.
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Plan of Correction
Program Supervisor will conduct training by 1/27/12 on agency's policy on records of services. Program Supervisor will monitor during monthly UR/QI meetings. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on a review of client records, the facility failed to document progress notes after each significant client contact in two of five client records.
The findings include:
Five complete client records were reviewed on December 1, 2011. Progress notes completed after each significant client contact were required in all five client records reviewed. Client Records # 4 and 5 did not include progress notes after each significant contact.
Client #4 was admitted to treatment on May 5, 2011 and discharged on August 3, 2011. Group sessions took place on 5/5/11, 5/11/11, 5/12/11, 5/18/11, 5/19/11, 6/1/11, 6/9/11, 6/14/11, 6/16/11, 6/21/11, 7/5/11, 7/7/11, 7/8/11, 7/12/11, 7/13/11, 7/15/11 and 7/19/11 according to the record of service; however, there were no corresponding progress notes for these group sessions in client record #4.
Client #5 was admitted to treatment on April 20, 2011 and discharged on July 20, 2011. Individual sessions took place on 4/22/11 and 5/27/11 and group sessions took place on 4/20/11, 4/22/11, 5/4/11, 5/5/11, 5/11/11, 5/12/11, 5/18/11, 5/19/11, 6/1/11, 6/9/11, 6/14/11, 6/15/11, 6/16/11, 6/21/11, 6/29/11, 7/5/11, 7/7/11, 7/8/11, 7/12/11, 7/13/11, 7/15/11 and 7/19/11 according to the record of service; however, there were no corresponding progress notes for these group sessions in client record #5.
Both client records # 4 and 5 contained a deficiency notification listing the missing documentation. An interview with the clinical supervisor took place on December 1, 2011 at which time it was confirmed that the aforementioned client records were missing the required documentation. It was reported that the counselors who were maintaining these client records are no longer employed at the facility.
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Plan of Correction
Program Supervisor will conduct training by 1/27/12 on agency's policy on Progress Notes. Program Supervisor will monitor during monthly UR/QI meetings. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within seven days of discharge in two of three client records.
The findings include:
Three discharged residential treatment and rehabilitation client records were reviewed on December 1, 2011. A discharge summary, which is to be completed within seven days of discharge, per facility policy, was required in all three client records. The facility did not document a discharge summary within seven days of discharge in client records # 4 and 5.
Client #4 was admitted to residential treatment and rehabilitation on May 5, 2011 and was discharged on August 3, 2011. A discharge summary was due to be completed by August 10, 2011. There was no discharge summary in client record #4.
Client #5 was admitted to residential treatment and rehabilitation on April 20, 2011 and was discharged on July 20, 2011. A discharge summary was due to be completed by July 27, 2011. There was no discharge summary in client record #5.
Both client records # 4 and 5 contained a deficiency notification listing the missing documentation. An interview with the clinical supervisor took place on December 1, 2011 at which time it was confirmed that the aforementioned client records were missing the required documentation. It was reported that the counselors who were maintaining these client records are no longer employed at the facility.
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Plan of Correction
Program Supervisor will conduct training by 1/27/12 on agency's policy on discharge summaries. Program Supervisor will monitor during monthly UR/QI meetings. |
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 as per facility policy in one of four client records.
The findings include:
Four complete outpatient client records were reviewed on December 1, 2011. Individual treatment and rehabilitation plans were required in all four client records. Per agency policy, "The individualized treatment plan shall be completed, approved and signed by the client and by the counselor within 4 sessions." Individualized treatment and rehabilitation plans were not documented as per agency policy in client record #7.
Client #7 was admitted to outpatient treatment on July 6, 2011. The 4th session was completed on August 8, 2011 and the individualized treatment and rehabilitation plan was due to be completed by that date. The individualized treatment and rehabilitation plan was completed on September 16, 2011.
An interview with the clinical supervisor took place on December 1, 2011 at which time the completion date for the individualized treatment and rehabilitation plan was confirmed.
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Plan of Correction
Program Director of Outpatient will conduct training by 1/27/12 on agency's policy that treatment plan be completed by the fourth individual session. Policy will reflect this. |
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 treatment plan updates as per agency policy in two of four client records.
The findings include:
Four complete intensive outpatient / outpatient client records were reviewed on December 1, 2011. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Treatment and rehabilitation plans were not updated at least every 60 days in client records # 7 and 9.
Client #7 was admitted to the intensive outpatient program on July 6, 2011. The preliminary treatment plan was completed on July 6, 2011. This treatment and rehabilitation plan was due to be reviewed and updated by September 6, 2011. The individualized treatment and rehabilitation plan (comprehensive) was completed with the client on September 16, 2011.
Client #9 was admitted to the outpatient program on August 25, 2011. The preliminary treatment plan was completed on August 25, 2011. This treatment and rehabilitation plan was due to be reviewed and updated by October 25, 2011. The individualized treatment and rehabilitation plan (comprehensive) was completed with the client on November 8, 2011.
An interview with the clinical supervisor took place on December 1, 2011. The completion dates for the treatment plans were confirmed at that time.
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Plan of Correction
Program Director of Outpatient will conduct training by 1/27/12 on agency's policy and time frames on treatment plan updates. Program Director will monitor during monthly UR/QI meetings. |
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 a review of client records, the facility failed to document case consultations as per facility policy in four of four client records.
The findings include:
Four complete client records were reviewed on December 1, 2011. Case consultations were required to be completed in all four client records. Per agency policy, case consultations are to be completed in the first thirty days of treatment for both intensive outpatient and outpatient clients. The intensive outpatient clients are then to have case consultations every thirty days thereafter and the outpatient clients are to receive case consultations every sixty days thereafter. Case consultations were not completed as required by agency policy in client records # 7, 8, 9 and 10.
Client #7 was admitted to intensive outpatient program on July 6, 2011. A case consultation was due to be completed by August 6, 2011 then again on September 6, October 6 and November 6, 2011. Case consultations were completed on September 16 and September 23, 2011.
Client #8 was admitted to the intensive outpatient program on May 16, 2011. A case consultation was due to be completed by June 16, July 16, August 16, September 16, October 16 and November 16, 2011. Case consultations were completed on June 14, August 11 and September 16, 2011.
Client #9 was admitted to the outpatient program on August 25, 2011. A case consultation was due to be completed by September 25 and November 25. One case consultation was completed on November 18, 2011.
Client #10 was admitted to the outpatient program on June 22, 2011. A case consultation was due to be completed by July 22, September 22 and November 22, 2011. One case consultation was completed on August 4, 2011.
An interview with the clinical supervisor took place on December 1, 2011 and the aforementioned information was confirmed.
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Plan of Correction
Program Supervisor will conduct training by 1/27/12 on agency's policy on case consults and their timeframes. Program Supervisor will monitor. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within seven days of discharge in three of three client records.
The findings include:
Three discharged outpatient client records were reviewed on December 1, 2011. A discharge summary, which is to be completed within seven days of discharge, per facility policy, was required in all three client records. The facility did not document a discharge summary within seven days of discharge in client records # 10, 11 and 12.
Client #10 was admitted to the outpatient program on June 22, 2011 and was discharged on September 14, 2011. A discharge summary was due to be completed by September 21, 2011. The discharge summary was completed on September 27, 2011.
Client #11 was admitted to the outpatient program on March 28, 2011 and was discharged on July 19, 2011. A discharge summary was due to be completed by July 26, 2011. The discharge summary was completed on August 1, 2011.
Client #12 was admitted to the outpatient program on May 11, 2011 and was discharged on July 28, 2011. A discharge summary was due to be completed by August 4, 2011. The discharge summary was completed on August 10, 2011.
An interview with the clinical supervisor took place on December 1, 2011 at which time the aforementioned information was confirmed.
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Plan of Correction
Program Director of Outpatient will conduct training by 1/27/12 on agency's policy and timeframe of discharge summaries. Program Director will monitor during monthly UR/QI meetings. |