INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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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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. |
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 upon the review of Administrative documentation, the project failed to have an annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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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). |
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 upon a review of the facility's policies and procedures and client records, the facility failed to document case consultations as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of case consultations:
"Case Consults are performed every 90 days for outpatient. Case Consults are performed more frequently whenever a client has a special problem (s). The Counselor shall meet with the Clinical Supervisor on a regular scheduled basis, i.e., weekly or bi-weekly, to discuss the overall progress or problems of each client. Documentation of the case consults shall be completed by the primary Counselor."
Seven client records requiring documentation of case consultations were reviewed on May 24, 2012. Two of seven client records, did not have documentation of a case consultation according to the project's policies, specifically #'s 4 and 7.
Client # 4 as admitted into treatment on February 9 2012. A case consultation was due by May 9, 2012 for client # 4. As of the date of inspection, there was no documentation of a case consultation for client # 4.
Client # 7 was admitted to treatment on July 26, 2011 and discharged on February 17, 2012. A case consultation was due by October 26, 2011 and again on January 26, 2012 for client # 7. A case consultation was documented on February 17, 2012 for client #7.
The findings were reviewed with the clinical supervisor during the exit interview.
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Plan of Correction
Treatment management procedures will be reviewed by the Program Supervisor in all staff meeting on July 26, 2012 with particular attention to the case consultation process. All clinical staff will be reminded that case consultations are due every 90 days for each client as well as completion for significant issues with the client and/or their treatment. Program Supervisor will monitor completion of case consultations through review of census in supervisory sessions. The Program Director will review compliance through the QI and UR reports completed by the Program Supervisor and Administrative Coordinator as well as random chart audits to ensure compliance. Any failure to comply with the above plan will result in corrective action. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document follow-up information as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of follow-ups:
" Follow Up:
Within seven (7) days of the date of a referral appointment made for a client leaving treatment, the referral shall be contacted by the Counselor to determine if the client kept the initial appointment and if the referral was appropriate. In the case of a client ending treatment without a referral appointment (ASA, Therapeutic Discharge, Completion who refuses further treatment), the client shall be contacted within 30 days directly by the counselor or supervisor ' s designee... "
Five client records requiring documentation of follow-ups were reviewed on May 24, 2012. Two out of five client records did not have documentation of a follow-up, specifically #'s 8 and 9.
Client #8 was admitted into treatment on October 4, 2011 and discharged on March 13, 2012. No referral was made. A follow-up was due by April 13, 2012 for client #8. As of the date of inspection, there was no documentation of a follow-up for client #8.
Client #9 was admitted into treatment on August 12, 2011 and discharged on February 6, 2012. No referral was made. A follow-up was due by March 6, 2012 for client #9. As of the date of inspection, there was no documentation of a follow-up for client #9.
The findings were reviewed with the clinical supervisor during the exit interview.
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Plan of Correction
Follow-up procedures have been reviewed with all staff during staff meeting on June 15, 2012.
All d/c records are processed thru the counselor to the admininstrative office. At that time the follow-up consent is pulled and filed for the follow-up call.
Follow-up calls will be completed no less than the last Friday of the month during the designated all staff meeting/call time if previous contact had not yet been made. Each counselor will complete the necessary follow-up record at the time of contact and/or attempted contact for his/her assigned clients.
Follow-up will be monitored by the Administrative Coordinat II for timeliness and completeness. Any follow-up not completed appropriately will be forwarded to the Program Supervisor who will enforce a corrective action plan with the responsible counselor.
The overall completion and follow through of Follow-Up Calls will be monitored by the Division Director in a monthly administrative meeting. |
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 of eight records.
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.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all Managers during the 1st 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 employees by January 31st, 2013 as per our policy.
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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 records the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
Two personnel records requiring documentation of HIV/AIDS and TB/STD training was reviewed on May 8, 2012. One out of two records, specifically record # 6, did not contain the required documentation. Employee # 6, a counselor , was hired on March 9, 2010. Training was due by March 9, 2011. As of the licensing inspection, there was no documentation of HIV/AIDS training for employee #6. The findings were confirmed with the training director during the administrative review and again with the clinical supervisor on May 24, 2012
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Plan of Correction
Individual training needs will be reviewed in staff meeting on July 27, 2012 regarding training hours needed per year for each position. In addition, the Program Supervisro will review specific core trainings that are needed within the first year of employment, including but not limited to HIV/AIDS, TB/STD. Scheduled training will be spread out through the year for each employee within the designated time frames for those trainings for each employee. Training reports are completed by the Administrative Coordinator to list trainings attended on a monthly basis. Program Supervisor will review the scheduling process for trainings and the responsibility of each counselor to track and schedule required trainings within the designated time frames. Program Director will monitor through compliance training reports and staff meeting minutes. Failure to adhere to the above plan will result in corrective action. |