INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1, 2017, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia DRC Inc., 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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704.11(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 a review of personnel records, the facility failed to ensure that all counselors received the required 25 hours training for training year 2016.
Employee # 6 was hired as a counselor on 2/6/15 and received 20 hours of training.
Employee #7 was hired as a counselor on 7/14/14 and received 23 hours of training.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Gaudenzia DRC Inc. has an Annual Training calendar. The training calendar is effective January 1st through December 31st. The Clinical Supervisor will review the training hours of each counselor quarterly. The goal is for each counselor to have 8 hours of training each of the first three quarters.
The Clinical Supervisor will do a quarterly supervision with counselors regarding their training hours and schedule trainings as needed for the upcoming quarter. The 4th quarter trainings scheduled will to ensure training hours (25) compliance.
Outpatient Director will review the training hours with Clinical Supervisor each quarter.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
During the review of the fire drill record for period November 2016 through October 2017, the facility failed to document that the fire alarms/smoke detectors were operative during the following drills; 9/17, 8/17.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director or designee will ensure that the alarm is activated during fire drills and evacuations and are documented according to licensing standards. |
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.
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Observations
Based on the review of the facility's consent to release form, the facilty limited the client's right to revoke their consent by stating that the client can verbally or in writing revoke their consent to the to the Project Director.
Additionally, the failed failed to obtain a valid consent for the following records, #1, 2, 5 and 6.
Client record #1 - Consent to release form, dated 6/9/17, for the client's insurer, was missing the client's signature. Additionally, the facility failed to document that the client was offered a copy or not.
The following urines were collected with no consent in file for the laboratory: 11/18/17, 11/21/17, 11/1/17, 10/20/17, 11/7/17, 10/31/17, 10/3/17, 10/10/17, 9/19/17, 9/12/17, 9/5/17, 8/30/17, 8/22/17, 8/15/17, 8/8/17, 8/1/17, 7/25/17, 7/21/17, 7/11/17, 7/6/17, 6/27/17.
Client record #2 - Consent to release form, dated 8/23/17, for parole, was missing the expiration date of the consent and whether the client was offered a copy not documented.
Consent to release form, dated 11/10/17, for another client was filed in client #2's record.
Client record #3 - The following urines were collected with no consent on file for the laboratory: 11/28/17, 9/26/17, 10/10/17, 9/19/17, 9/12/17, 11/21/17, 10/18/17, 10/30/17, 10/18/17, 11/14/17, 11/7/17, 8/22/17, 10/30/17, 10/27/17, 10/18/17, 10/3/17, 9/26/17, 9/19/17, 9/12/17, 9/5/17, 8/29/17 and 8/8/17.
A fax, dated 10/10/17, was reviewed, but the facility failed to have a consent on file for that agency.
Client record #4 - Consent to release form, dated 4/11/17 for the client's emergency contact, was missing the date the client signed.
Client record #8 - Urines were collected with not consent on file for the laboratory.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Intake Supervisor will review intake documentation daily to ensure that the client has initialed whether they declined or accepted copies of their consent to release forms. If it is not indicated the client will be contacted and offered copies of their consent forms as needed.
The client has the right to revoke their consent by stating verbally or in writing to the Project Director, Clinical Supervisor, or Outpatient counselor. The consent to release information forms will be revised to state this. The procedures for a client rescinding consent will be reviewed during Outpatient staff meeting on 1/9/18.
The Clinical Supervisor will review intake documentation during monthly open chart audits to ensure that there is evidence the client was a offered copies of their consent to release forms. If it is not indicated the client will be contacted and offered copies of their consent forms as needed.
The Clinical Supervisor will review open charts to ensure that all consent to release forms are valid and signed by staff and client.
Client #1 is unavailable to sign 6/9/17 consent to release form. The Intake Assessment counselor will document the client was offered a copy.
Client #2 - Consent to release form, dated 8/23/17, will have the expiration date entered by the Intake Assessment counselor and it will be documented that the client was offered a copy. The consent to release form, for another client, will be removed from Client #2 chart by the Intake Assessment counselor.
Client #3 - The consent to release form for the laboratory will be signed by the client. The Program Director will document the client was offered a copy. The consent to release information for the agency that was faxed will be signed by the client. The Program Director will document the client was offered a copy.
Client #4 - Consent to release form, dated 4/11/17, will have the date it was signed entered by the Intake Assessment counselor.
Client #8 - The consent to release form for the laboratory will be signed by the client. The Program Director will document the client was offered a copy.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of the facilty's Client Rights form failed to included the following verbiage verbatim:
(1)The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Gaudenzia DRC Client Bill of Rights will be edited by Outpatient/Intake Assessment Director to include the verbiage, verbatim, regarding no discrimination in the provision of services....
The Intake Supervisor will
ensure the revised Gaudenzia DRC Client Bill of Rights is being used effective 1/5/18.
The Intake Supervisor will review all intake documentation to ensure that all of the signatures and dates have been obtained.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's unusual incidents, the facility failed to send notification of an unusual incident to the Department within 48 hours.
Unusual incident took place on 10/15/17.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Outpatient Director will file a written unusual incident report to the Department within 3 business days following an unusual incident involving death, serious injury due to trauma, suicide or other unusual circumstances.
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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 10 client records, the facility failed to document psychosocial evaluations that included the counselor's clinical impressions in client records, #1, 2, 4, 9 and 10.
Client #1's psychosocial evaluation completed on 7/4/17.
Client #2's psychosocial evaluation completed on 9/20/17
Client #4's psychosocial evaluation completed on 5/9/17
Client #9's psychosocial evaluation completed on 5/25/17
Client #10 was admitted on 4/8/14. The psychosocial evaluation was not completed as of the date of the licensing inspection
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
The client will meet with Primary Counselor for individual counseling sessions once weekly. The counselor will begin gathering data to complete the Psychosocial History. Upon completion of the Psychosocial History the counselor will write a clinical psychosocial assessment and submit to Clinical Supervisor for review prior to the next individual session. The clinical psychosocial assessment will be clearly indicated as separate from the psychosocial history and the first and last name of the participant will be indicated.
There will an in-service staff review on completing the
bio-psychosocial and clinical assessment during the Outpatient Staff meeting on 1/2/18.
Client #1 clinical assessment was completed on 7/4/17. The Clinical Observation section has been high-lighted.
Client #2 clinical assessment was completed on 9/20/17. The Clinical Observation section has been high-lighted.
Client #4 clinical assessment was completed on 5/9/17. The Clinical Observation section has been high-lighted.
Client #9 clinical assessment was completed on 5/25/17. The Clinical Observation section has been high-lighted.
Client #10 There was no participant on the active or discharge roster for 2016 who was admitted on 4/8/14.
There will be an in-service staff training on clinical observations and assessment during the Outpatient Staff meeting on 1/31/17.
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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 in two of six records reviewed, #1 and 2.
Client #5 -The counselor failed to document an update to the stated goals for treatment plan updates, 9/18/17 and 11/14/17.
Client #2 - The treatment plan update was not documented as of the date of the licensing inspection. The comprehensive treatment plan was documented on 9/20/17.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client Treatment Plans are to be reviewed and updated every 30 days for 1B level of care. Client Treatment Plans are to be reviewed and updated every 60 days for 1A level of care. Clinical Supervisor/Director will be responsible for treatment plan review and accuracy before being submitted to the Doctor for his/her signature.
Client #1 treatment plans have been reviewed and updated on 7/18/17, 9/18/17, and 11/14/17.
Client #2 treatment plans have been reviewed and updated on 9/20/17 and 11/15/17.
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record in the following records reviewed.
Client #1 - Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 11/28/17, 11/21/17, 10/31/17, 10/24/17, 10/20/17, 10/10/17, 9/4/17, 8/15/17, 8/1/17, 8/8/17, 8/8/17, 7/25/17, 7/21/17, 7/6/17. (Group sessions) 11/27/17, 11/7/17, 11/14/17, 10/10/17, 9/29/17, 9/22/17, 9/5/17 (2 notes), 8/1/17, 8/8/17, 8/15/17, 7/11/17, 6/20/17, 6/27/17.
Record of service - services rendered documented on the record of service, but no progress notes provided for review - (Group sessions) 10/3/17, 9/12/17, 8/22/17, 8/24/17, 8/30/17.
Client record #2 - Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 11/29/17, 11/22/17, 11/15/17, 11/1/17, 9/27/17, 9/20/17, 9/13/17, 9/6/17, 8/30/17, 8/23/17 (2 notes). (Group sessions) 11/24/17, 11/13/17, 11/3/17, 9/29/17, 9/22/17 and 9/18/17.
Record of service - services rendered documented on the record of service, but no progress notes provided for review - (Group sessions) 10/30/17, 10/27/17, 10/23/17, 10/20/17, 10/16/17, 10/13/17, 10/11/17, 10/2/17.
Client record #3 - Progress notes reviewed, but services not documented on the client's record of service - (Individual session) 11/28/17. (Group sessions) 11/21/17, 11/7/17, 11/8/17, 11/4/17, 10/31/17, 10/3/17, 9/26/17, 9/19/17, 9/5/17, 8/31/17, 8/22/17, 8/9/17, 8/8/17 and 8/2/17.
Client record #4 - Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 11/28/17 and 11/21/17. (Group sessions) 11/16/17, 11/14/17, 11/7/17, 10/3/17, 10/10/17, 9/26/17, 8/22/17, 8/24/17, 8/29/17, 8/2/17, 8/5/17, 8/7/17, 8/9/17, 8/10/17, 8/12/17, 8/14/17, 7/1/17, 7/3/17, 7/5/17, 7/10/17, 7/12/17, 6/21/17, 6/24/17, 6/28/17, 6/3/17, 6/10/17, 6/14/17, 5/27/17, 5/1/17, 5/21/17, 5/13/17, 5/9/17, 4/19/17, 4/22/17, 4/26/17, 4/29/17, 4/15/17 and 4/16/17.
Record of service - services rendered documented on the record of service, but no progress notes provided for review - (Individual sessions) 7/25/17 and 7/18/17 (Group sessions) 11/2/17, 10/31/17 and 10/24/17.
Client record #5 - Discharge summary and follow-up attempt not documented as of the date of the licensing inspection. The client ' s discharge date was 10/14/17.
Client record #6 - Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 6/8/17, 6/1/17, 5/25/17 and 3/28/17.
Record of service - services rendered documented on the record of service, but no progress notes provided for review - (Group sessions) 5/19/17, 5/12/17, 5/2/17, 4/28/17, 4/26/17, 4/27/17 and 4/2/17.
Follow-up attempt not documented as of the date of the licensing inspection. The client's discharge date was 6/21/17.
Client record #7 - Record of service - services rendered documented on the record of service, but no progress notes provided for review - 11/6/17, 10/30/17, 10/23/17, 10/16/17, 9/26/17, 9/25/17, 9/18/17, 9/12/17, 9/6/17, 9/2/17, 8/29/17, 8/28/17, 8/21/17, 8/14/17, 8/12/17, 8/5,17, 8/4/17, 7/14/17, 7/8/17, 7/7/14, 6/14/17, 6/9/17, 6/7/17, 6/2/17, 5/24/17, 5/19/17, 5/17/17, 5/12/18 and 5/5/17.
Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 10/13/17, 7/31/17, 7/24/17, 6/26/17, and 6/19/17.
Client record #8 - Client #8 was admitted on 7/31/17 and discharged on 11/9/17. The facility failed to document a case consultation as of the date of the client's discharge.
Record of service - services rendered documented on the record of service, but no progress notes provided for review -(Individual sessions) 10/9/17 and 10/16/17.
Progress notes reviewed, but services not documented on the client's record of service - (Individual sessions) 8/4/17 and 8/28/17.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All services rendered to a client shall be documented on the Outpatient Client Contact Sheet. The Client Contact Sheet is filed in the client's clinical chart after the services have been recorded for monthly billing.
The Counselor or staff person providing the service shall record the date a service is provided and complete the group or individual note.
The Clinical Supervisor will review the Outpatient Service Record and supporting documentation when doing monthly open chart audits to ensure documentation is being completed and filed in the client record.
Client #1 client contact sheets will be filed in the clinical chart by the Record Room Clerk.
Client #2 client contact sheets will be filed in the clinical chart by the Record Room Clerk.
Client #3 client contact sheets will be filed in the clinical chart by the Record Room Clerk.
Client #4 client contact sheets will be filed in the clinical chart by the Record Room Clerk.
Client #5 client contact sheets will be filed in the clinical chart by the Record Room Clerk.
Client #6 client contact sheets will be filed in the clinical chart by the Record Room Clerk.
Client #7 client contact sheets will be filed in the clinical chart by the Record Room Clerk.
Client #8 client contact sheets will be filed in the clinical chart by the Record Room Clerk.
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