INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 2, 2011 licensure renewal inspection. The follow-up inspection was conducted on
November 21, 2011 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:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the facility's administrative material and a personnel record, the facility failed to document weekly supervision notes of the clinical supervisor providing direct observation with the counselor assistant.
The findings include:
On November 21, 2011, the facility's administrative material and a personnel record requiring documentation of weekly supervision notes of the clinical supervisor giving direct observation to the counselor assistant were reviewed. The facility did not provide documentation of weekly supervision notes of the clinical supervisor providing direct observation with the counselor assistant in one of one personnel record reviewed, specifically, personnel record # 3
Employee # 3 is a counselor assistant, was hired on August 1, 2011, and has a qualifying bachelor's degree for the position of counselor. The facility was required to provide documentation of weekly supervision notes of the clinical supervisor providing direct observation with employee # 3. However, the facility's administrative material and personnel record # 3 only included documentation of supervision notes of the clinical supervisor providing direct observation with employee # 3 on the following dates: August 2, 2011; August 8, 2011; August 19, 2011; August 26, 2011; September 2, 2011; September 15, 2011; and September 21, 2011.
The findings were confirmed during an ongoing dialogue with the program supervisor on November 21, 2011 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
Clincal/Program supervisor will provide close supervision of counselor assistant and document the supervisions on the proper forms as required when providing supervision.
Going forward the Program Director will monitor closely all required documentation needed for counselor assistants that indicate clinical/program supervisor providing supervision on weekly bases for the first 90 days of employment. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of the problems encountered.
The findings include:
Fire drill records were reviewed on November 21, 2011. The records were reviewed from the period covering July 2011 to November 2011. The facility did not have documentation for problems encountered at the time of the drill, in five of five months reviewed, specifically, July 27, 2011; August 19, 2011; September 16, 2011; October 4, 2011; and November 17, 2011.
The findings were confirmed during an ongoing dialogue with the facility director on November 21, 2011 from approximately 11:00 A.M. to 11:30 A.M.
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Plan of Correction
Moving forward the agency will provide written documentation of all fire drills that include any problem encountered while the fire drills were being conducted. Program Director will monitor the documentation needed to verify the agency fire drills as required by licensure. After each fire drill the Program Director will follow up with staff on duty to provide written documentation that the fire drills took place and the outcome of each drill. |
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 client records, the facility failed to document a psychosocial evaluation in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Procedure For Intake Documentation Of Histories," states:
"Psychosocial Assessment:Upon completion of the psychosocial histories, the Counselor will write a narrative psychosocial assessment prior to the next scheduled individual counseling session. The assignment shall include a client description, the referral source, presenting and underlying problems, treatment issues, client coping mechanisms, factors contributing to addiction, client strengths and weakness, client motivation, support system, client response during the intake, receptivity to treatment and client attitude, ability to participate in treatment, client motivation, support systems, treatment recommendations, diagnosis and prognosis. Emphasis is placed on the documentation of the client's strengths, abilities and preferences (SNAP). The assessment shall be submitted promptly (not to exceed 3-5 treatment days after the client's admission to the program) to the Clinical Supervisor for review and signature for residential and within 3 individual sessions for outpatient."
On November 21, 2011, seven client records requiring documentation of psychosocial evaluations were reviewed. The facility did not document a psychosocial evaluation according to their policy and procedures in six of six records reviewed, specifically, client records # 1, 3, 4, 5, 6, and 9.
Client # 1 was admitted July 14, 2011. The psychosocial evaluation was due by the third individual session on August 10, 2011. However, the psychosocial evaluation did not include a date of completion. Also, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, negative factors, and attitude toward treatment.
Client # 3 was admitted August 2, 2011. The psychosocial evaluation was completed on August 16, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, coping mechanisms, negative factors, and attitude toward treatment.
Client # 4 was admitted August 26, 2011. The psychosocial evaluation was completed on August 19, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, and negative factors.
Client # 5 was admitted August 10, 2011. The psychosocial evaluation was completed on August 23, 2011; however, the psychosocial evaluation did not include an evaluation of the client's support systems, coping mechanisms, and negative factors.
Client # 6 was admitted August 24, 2011. The psychosocial evaluation was completed on August 31, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
Client # 9 was admitted September 14, 2011. The psychosocial evaluation was completed on October 16, 2011; however, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.
The findings were confirmed during an ongoing dialogue with the program supervisor on November 21, 2011 from approximately 3:30 P.M. to 4:00 P.M.
This is a repeat citation. The facility was cited on June 2, 2011 and May 18, 2010 for noncompliance with this standard.
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Plan of Correction
Director and Supervisor(s) will meet with the clinical staff to discuss policy and procedures of "Psychosocial Assessments." During the meeting the timeliness of providing the assessment will be the focuses of the meeting. Going forward the Clincal Supervisor & Program Supervisor will assure that all psychosocials evaluations include an evaluation of the individuals assets/strenghts, support systems, coping mechanisms, negative factors and their attitude toward treatment. All new staff is schedule to attend an in-service training on Biopsychosocial on February 17, 2012 and this issues/concerns will be implemented in the training. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan.
Also, based on a review of client records, the facility failed to clearly identify the short-term or long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan.
The findings include:
On November 21, 2011, six client records requiring documentation of short-term and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in five of six records reviewed, specifically, client records # 3, 4, 6, 7, and 9. The facility also did not clearly identify short-term or long-term goals for treatment in one of six records reviewed, specifically, client record # 5.
Client # 3 was admitted August 2, 2011. The individual treatment and rehabilitation plan was completed on September 21, 2011, but it did not include documentation of the long-term goals for treatment as of November 21, 2011.
Client # 4 was admitted August 26, 2011. The individual treatment and rehabilitation plan was completed on August 26, 2011, but it did not include documentation of the long-term goals for treatment as of November 21, 2011.
Client # 5 was admitted August 10, 2011. The individual treatment and rehabilitation plan was completed on September 20, 2011, but the short-term or long-term goals for treatment were not clearly identified as of November 21, 2011.
Client # 6 was admitted August 24, 2011. The individual treatment and rehabilitation plan was completed on September 27, 2011, but it did not include documentation of the long-term goals for treatment as of November 21, 2011.
Client # 7 was admitted September 13, 2011. The individual treatment and rehabilitation plan was completed on October 13, 2011, but it did not include documentation of the long-term goals for treatment as of November 21, 2011.
Client # 9 was admitted September 14, 2011. The individual treatment and rehabilitation plan was completed on October 7, 2011, but it did not include documentation of the long-term goals for treatment as of November 21, 2011.
The findings were confirmed during an ongoing dialogue with the program supervisor on November 21, 2011 from approximately 3:30 P.M. to 4:00 P.M.
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Plan of Correction
Program Director/Supervisors will conduct an in-service training on treatment plans to discuss the areas of concern which include long and short-term goals as indictaed on the newly revised treatment plans. Going forward the clinical staff will include on all treatment plans the individuals long & short term goals as identify by both the individual and staff. Supervisor(s) will review all treatment plans to assure that the plans includes the individuals long & short-term goals. |
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 a treatment and
rehabilitation plan update.
Also, based on a review of client records, the facility failed to document a treatment and rehabilitation plan update in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Treatment Plan Reviews," stated:
"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. Any goal or action step
additions, revisions and deletions shall also be reflected. Goal and action step changes shall
also be reflected on the treatment plan. The update shall be signed by the Counselor and
submitted to the Clinical Supervisor for review and signature."
On November 21, four client records requiring documentation of a treatment and rehabilitation plans were reviewed. The facility did not document a treatment and rehabilitation plan update in one of four records reviewed, specifically, client record # 3. The facility also did not document a treatment and rehabilitation plan update according to their policy and procedures in two of four records reviewed, specifically, client records # 5 and 6.
Client # 3 was admitted August 2, 2011 and the individual treatment and rehabilitation plan was completed on September 21, 2011. The treatment plan update was due November 20, 2011; however, client record # 3 did not include documentation of a treatment plan update as of November 21, 2011.
Client # 5 was admitted August 10, 2011. The individual treatment and rehabilitation plan was completed on September 20, 2011 and the treatment plan update was completed on November 16, 2011. However, the treatment plan update did not include an indication of the client's progress as relative to the treatment plan goals and objectives as of November 21, 2011.
Client # 6 was admitted August 24, 2011. The individual treatment and rehabilitation plan was completed on September 27, 2011 and the treatment plan update was completed on October 25, 2011. However, the treatment plan update did not include an indication of the client's progress as relative to the treatment plan goals and objectives as of November 21, 2011.
The findings were confirmed during an ongoing dialogue with the program supervisor on November 21, 2011 from approximately 3:30 P.M. to 4:00 P.M.
This is a repeat citation. The facility was cited on June 2, 2011; November 19, 2010; and May 18, 2010 for noncompliance with this standard.
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Plan of Correction
Program Director, Program Supervisor & Clinical supervisor will conduct weekly auidts of all clinical charts as needed to assure treatment plan updates are being process at least every 60 days following the comprehensive treatment plan as indicated in our policy & procedure manual.
Moving forward the supervisors will discuss the policy & procedures with clinical staff during the weekly team meetings to assure that the clinical staff is reviewing and processing updated treatment plans as required for the indiviudal(s).
According to the audit & a follow-up review individual chart # 3 updated treatment was not done at the time of the audit, the chart has been reviewed by the management staff and forward to the clincal staff responsible for the updated treatment plan. Clinical staff completed the updated treatment plan in the individual chart # 3. |