INITIAL COMMENTS
|
This report is a result of an on-site licensure inspection conducted on June 1 - 2, 2011 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.
|
Plan of Correction
|
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on a review of personnel records and a conversation with the human resource director, the facility failed to ensure that each counselor assistant documented to the facility director that he is working toward counselor status. In addition, the facility failed to ensure that each counselor assistant met the requirements for the position of counselor assistant within 5 years of employment.
The findings include:
On May 9 - 11, 2011 one record was reviewed for and required documentation for the qualifications for the position of counselor. The facility failed to provide verification that employee # 6 was working toward counselor status.
Based on a conversation with the human resource director, employee # 6 has been working as a counselor assistant at different facilities within the project for over 12 years.
At the time of review on May 9 -11, 2011 the facility failed to verify and document that employee # 6 was working toward counselor status.
The Human Resource Director confirmed that employee # 6 did not verify or document working toward counselor status.
In addition, the regulation states that a counselor assistant shall meet the requirements for counselor within 5 years of employment; employee # 6 exceeded the 5 year timeframe as he has been working at different facilities within the project as a counselor assistant for over 12 years. This information was confirmed by the Human Resource Director.
|
Plan of Correction
Employee number #6 will be demoted and transferred to a position that meets his current employment criteria. Moving forward the agency will follow the guidelines and requirements of licensure and not hire anyone that has been employed more than five years as a counselor assistance and failed to follow through with educational goals to sustain a position in counseling. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of personnel records, a review of the Staffing Requirements Facility Summary Report completed by the facility on 4/20/11, and a conversation with the Human Resource Director, the project failed to ensure that each employee working as a counselor assistant met the requirements for the position of counselor assistant within 5 years of employment.
The findings include:
On May 11, 2011 employee # 6 was determined unqualified for the position of counselor assistant as he exceeded the 5 year timeframe to obtain the necessary credentials to qualify for a counselor. Based on a conversation with the Human Resource Director, employee # 6 has been working as a counselor assistant at different facilities within the project for over 12 years, thus exceeding the 5 year timeframe as outlined in regulation 709.10(c).
The facility completed the Staffing Requirements Facility Summary Report on 4/20/11 and signed the form on 6/2/11. The Staffing Requirements Facility Summary Report listed employee # 6 as a counselor assistant and had assigned him a caseload of 8 clients.
However, since employee # 6 is unqualified for the position of counselor assistant, the facility has an unassigned caseload.
The facility director confirmed that employee # 6 was assigned a caseload of 8:1 and did not refute the findings during the exit interview on June 2, 2011.
|
Plan of Correction
Employee number #6 is schedule to be transferred and demoted to a position that meets his employment criteria. The assigned caseload has been reassigned to another counselor who meets the criteria to provide services for the unassigned caseload. Moving forward the agency will assure that each counselor meets the requirements and regulations of licensure outpatient caseload. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on observation during the physical plant inspection and an interview with the facility director, the facility failed to ensure that there were no portable heaters within the facility.
The findings include:
A physical plant inspection was conducted at approximately 3:00 PM on June 2, 2011.
Portable space heaters that were not permanently mounted or installed were observed in three individual offices, office # 115, 119, and 120.
The facility director confirmed that the three offices had portable space heaters that were not permanently mounted or installed.
|
Plan of Correction
Program Director has made staff aware that portable heaters are not permitted into the facility during a staff meeting as well as generating a memo. Moving forward the program Director will assure that no portable heaters of any kind be brought into the site. All new hires will become aware of the license regulations of Heating and Cooling proir to becoming employed at this location. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the facility's fire drill log and an interview with the facility director, the facility failed to conduct an unannounced fire drill at least once a month.
The findings include:
The facility's fire drill log was reviewed on June 1, 2011.
The fire drill log failed to include documentation of a fire drill for the month of January 2011.
The facility director was interviewed in regards to the lack of documentation for the January 2011 fire drill. The facility director confirmed that an unannounced fire drill was not conducted for the month of January 2011.
This outpatient program is located in a five story building owned by Gaudenzia; this building also provides residential treatment services. The facility director was asked if this Gaudenzia building provided any fire drills for the month of January 2011, the facility director stated that an unannounced fire drill was not conducted in the Gaudenzia building for the month of January 2011 as she would have documented the fire drill in her facilities fire drill log.
|
Plan of Correction
Going forward the Program director will assure that unannounced fire drills are conducted once monthly and documented in the fire drill log the outcome of each fire drill. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, and a review of the facility's policies and procedures manual, the facility failed to document a psychosocial evaluation in accordance with facility policy in four of eleven client records.
The findings include:
The facility's policy titled "Biopsychosocial" states: "The biopsychosocial assessments and diagnostic summary must be complete and comprehensive in its entirety. All presenting problems are to be listed. Client strength and weaknesses are to be included. It must be obvious to the reader that the assessment and diagnostic summary was based on information that was recorded in the biopsychosocial. Initial clinical goals and objectives that are listed in the assessment component must be addressed and further developed in the clinical problem list. The clinical problem list and the summary assessment are the bridge to the client's initial treatment plan." "The biopsychosocial, with accompanying assessment and diagnostic summary must be completed within 3-5 days of the client's admission. The QI Committee reviews every fourth client per counselor to ensure that the biopsychosocial is comprehensive, that the initial assessments and diagnostic summary are formulated upon information that is contained in the biopsychosocial and that the proposed initial individualized treatment plan is relevant to the content of the data assessed."
Eleven client records were reviewed for documentation of a psychosocial evaluations on June 1 - 2, 2011. The facility failed to document a psychosocial evaluation in accordance with facility policy in client records # 2, 6, 9, and 10.
Client # 2 was admitted to the program on 3/18/11, and at the time of review was an active client. Per facility policy, a psychosocial evaluation is to be documented within 3-5 days of the client's admission. The facility had failed to document a psychosocial evaluation in client record #2 at the time of the review on 6/1/11.
Client # 6 was admitted to the program on 3/25/11, and at the time of review was an active client. Per facility policy, a psychosocial evaluation is to be documented within 3-5 days of the client's admission. The facility had failed to document a psychosocial evaluation in client record # 6 at the time of review on 6/1/11.
Client # 9 was admitted to the program on 1/6/11, and discharged on 3/4/11. Per facility policy, a psychosocial evaluation is to be documented within 3-5 days of the client's admission. The facility failed to document a psychosocial evaluation in client record # 9 at the time of review on 6/1/11.
Client # 10 was admitted to the program on 2/1/11, and discharged on 3/28/11. Per facility policy a psychosocial evaluation is to be documented within 3-5 days of the client's admission. The facility failed to document a psychosocial evaluation in client record # 10 at the time of review on 6/1/11.
This issue was discussed with the Facility Director during the exit interview on June 2, 2011 and the findings were not refuted.
This is a repeat citation.
The facility was previously cited on 5/18/10, 9/18/06, and 8/3/05 for failing to document a psychosocial evaluation in accordance with facility policy.
|
Plan of Correction
According to Gaudenzia Policy 709.51.b.3 (10) Psychosocial Assessment: Upon completion of the psychosocial histories, the counselor will write a narrative psychosocial aassessment prior to the next schedule individual counseling session. The assessment shall be submitted promptly to clinical supervisor for review and signature (not to exceed 3-5 treatment days after the client's admission to program) for residential and within 3 sessions for outpatient. Moving forward Program Director and Supervisor(s) will assure that each clinical charts have a psychosocial assessment after completion of gathering psychosocial histories from Person-In-Recovery (client's) following the PIR three session. Program Director and supervisors will audit clinical charts weekly to assure that psychosocial assessments have been completed and signed by reviewer(s). |
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:
|
Observations
Based on a review of client records and a review of the facility's policies and procedures manual, the facility failed to document an individual treatment plan in accordance with facility policy in five of ten client records.
The findings include:
The facilities policy titled "Procedure for Intake Documentation of Histories" states:
"11. Treatment Plan: Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan citing a diagnosis, specific problems, goals, action steps to achieve the goals and target dates. The goals shall reflect the discharge criteria. A 'Problem' is defined as a concrete issue or need which requires attention during treatment. A 'goal' shall be a statement written in measurable observable terms, describing a specific aim or outcome of therapy and may be short-term or long-term. A 'plan' shall consist of action steps and procedures performed by the counselor and client in order to achieve the goals identified. It shall be explained to the client that the treatment plan is designed to provide direction and reinforcement in the treatment process and to serve as a contract. The discharge goals will be reflected in the Treatment Plan goals. The counselor and client shall identify at least three priority goals, which will be the focus of treatment for the initial 30 days of treatment. In addition, the client shall make a list of problems/issues that they identify as important to address while in treatment. One of the three goals shall be in the client's own words based on the identified list of concerns. 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 and by the second or third counseling outpatient appointment and updates every 30 days for residential and the 10th session for outpatient or 90 day (which ever comes first)."
On June 1-2, 2011 ten client records were reviewed for documentation of an individual treatment and rehabilitation plan. The facility failed to document an individual treatment and rehabilitation plans, in accordance with facility policy, in client records # 3, 6, 9, 10, and 12.
Client # 3 was admitted to the program on 1/18/11, and at the time of review was an active client. Per facility policy, an individualized treatment plan shall be documented by the second or third counseling outpatient appointment. The facility failed to document an individualized treatment plan in client record # 3 at the time of review on 6/2/11.
Client # 6 was admitted to the program on 3/25/11, and at the time of review was an active client. Per facility policy, an individualized treatment plan shall be documented by the second or third counseling outpatient appointment. The facility failed to document an individualized treatment plan in client record # 6 at the time of review on 6/2/11.
Client # 9 was admitted to the program on 1/6/11, and discharged on 3/4/11. Per facility policy, an individualized treatment plan shall be documented by the second or third counseling outpatient appointment. The facility failed to document an individualized treatment plan in client record #9 at the time of review on 6/2/11.
Client # 10 was admitted to the program on 2/1/11, and discharged on 3/28/11. Per facility policy, an individualized treatment plan shall be documented by the second or third counseling outpatient appointment. The facility failed to document an individualized treatment plan according to policy in client record # 10. The individualized treatment plan for client # 10 was not documented until 3/11/11, which was the client's 15th counseling session. In addition, client # 10 receives medical assistance funding, but the medical director failed to sign the individualized treatment plan.
Client # 12 was admitted to the program on 2/14/11, and at the time of review was an active client. Per facility policy, an individualized treatment plan shall be documented by the second or third counseling outpatient appointment. The client's third counseling session was conducted on 2/17/11. The individualized treatment plan for client # 12 was not documented until 3/17/11. The facility failed to document an individualized treatment plan according to policy for client # 12.
This issue was discussed with the Facility Director during the exit interview on June 2, 2011 and the findings were not refuted.
|
Plan of Correction
Clincal Supervisor, Program Supervisor and Program Director will review clinical charts within the first 30 days of treatment to assure that counselors are providing individualized treatment plans in every Person-In-Recovery (PIR) charts. Moving forward staff will have an in-service training on treatment plan which will include the timeframe that treatment plans are expected to be in clincal charts based upon the agency policy & procedure mannual. |
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.
|
Observations
Based on a review of client records, and a review of the projects policy and procedures manual, the facility failed to document a treatment plan update per policy in two of seven client records.
The findings include:
The facility's policy titled 'Treatment Plan Reviews' states: "The Counselor shall complete a treatment plan review and update 30 days after the date of the original individual treatment plan for residential, (and every 30 days thereafter), 14 days after the date of the original individual treatment plan for short-term (and every 14 days thereafter) and 60 days after for outpatient and every 60 days thereafter. This review shall include an assessment of the client's progress with the goals identified on the treatment plan along with a specific indication of how each goal has been impacted."
Seven client records were reviewed for documentation of a treatment and rehabilitation plan update on June 1 - 2, 2011. The facility did not document a treatment plan update, as per facility policy, in client records # 3, and 8.
Client # 3 was admitted to the program on 1/18/11, and at the time of review was an active client. The individualized treatment plan was not documented in client record # 3 at the time of the review on 6/2/11. In addition, the facility failed to document a treatment and rehabilitation plan update at the time of review on 6/2/11.
Client # 8 was admitted to the program on 10/5/10 and the last counseling session was on 1/25/11. The client was discharged on 2/25/1. The individualized treatment plan was documented on 10/26/10. The treatment and rehabilitation plan was updated on 12/28/10, however, it did not include an assessment of progress, nor was it signed by the medical director as client # 8 receives medical assistance.
This issue was discussed with the Facility Director during the exit interview on June 2, 2011 and the findings were not refuted.
This is a repeat citation.
The facility was previously cited on 5/18/10 for failing to document treatment plan updates in accordance with facility policy.
|
Plan of Correction
Clincal Supervisor, Program Supervisor and Program Director will review clinical charts weekly during our weekly staff meeting to assure treatment plan updates are being conducted every 60 days as stated in our policy & procedure mannual. Moving forward the supervisors will review with clincal staff bi-weekly in team meetings updated treatment planning and document that the area of concerns was communicated and follow-up by clincal staff. |
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.
|
Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states: "All clients are followed up after discharge. Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt. Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder. In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form]. Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder. .Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals."
The facility's policy and procedure manual contained a second written policy titled: "FOLLOW UP INFORMATION." This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
|
Plan of Correction
Facility policy and procedure mannual will be reviewed by the corporate office and revised to accurately reflect the procedures for follow-up. Moving forward the agency will revise the follow-up policy to reflect the procedures needed to follow-up on person-in-recovery (clients) after leaving the facility for further treatment and/or leaving against staff advice. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On June 2, 2011 the facility was again found to be out of compliance with the following standards:
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
This area of noncompliance was also identified during the licensing inspections conducted on:
5/18/10 (plan of correction submitted on 6/14/10 and approved on 6/23/10)
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
This area of noncompliance was also identified during the licensing inspections conducted on:
5/18/10 (plan of correction submitted on 6/14/10 and approved on 6/23/10)
|
Plan of Correction
Intake and admissions: (psychosocial evaluations) are expected to be completed within three sessions for outpatient. Going forward the Program Director and supervisors will audit clinical charts weekly to assure that psychosocial assessments are completed by counselors within the timeframe indicated. The clinical charts will be reviewed by sipervisor(s) and signatures will be applied to each assessment after review.
Treatment and rehabilitation plans: (updated treatment plans)Program Director and Supervisor(s) will conduct an in-service training on updated treatment plans which will include timeframes when treatment plans are due for clinical charts. Moving forward the facility will assure that clinical charts have updated treatment plans as scheduled at least every 6o days for PIR. |