INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Montgomery Outpatient 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 and a plan of correction is due on June 30, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel training records, facility policies and procedures and an interview with the Training Manager, the facility failed to provide documentation of TB/STD training in one of four personnel training records as per facility policies and procedures.
The findings include:
Facility policy titled, Standard: 704.11.c Subject: General Training dated January, 2009 stated:
Core staff training shall be completed within the first three months of employment and
include, but not be limited to:
DOC - Orientation - first 40 hours as per American Corrections Association standards
HIV/AIDS - 6 hours for counselors orientation period
TB/STDS - 4 hours for counselors within three months of employment and other staff
within two years
Fire Safety - [do a preliminary review the first week]
CPR - orientation period
Four personnel training records were reviewed on May 7, 2010. All four records required documentation of TB/STD training per facility policy. The facility did not provide documentation of 4 hours of TB/STD training in personnel training record # 4.
Employee #4 is a counselor and was hired on August 25, 2008. TB/STD training was due to be completed no later than August 25, 2009. As of the date of inspection, the facility documented only 3 hours of TB/STD training for employee #4.
An interview with the Training Manager on May 7, 2010 confirmed that employee #4 did not have documentation of 4 hours of TB/STD training.
|
Plan of Correction
GMCOP was not in compliance with Standard 704.11.c General Training because Counselor #4 should have had all of his core trainings within the first three months of hire.He was hired August 25,2009.As of the date of the inspection the facility had documented only 3 hours of TB/STD training for counselor #4.
Program Director has registered Counselor #4 for TB/STD training at the Nelson center. He is registered for 9/30/10.To ensure compliance with this action the Divisional Director will follow up----10/5/10 |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
|
Observations
Based on a tour of the facility ' s physical plant, the facility failed to display a service fee schedule in a prominent place.
The findings include:
A tour of the facility ' s physical plant was conducted on June 2, 2010 at approximately 3:00 PM. A service fee schedule was required to be posted in a prominent place. The facility did not have a service fee schedule posted at the time of inspection.
The facility director confirmed that a fee schedule was not posted at the time of inspection.
|
Plan of Correction
Based on a tour of GMCOP's Facility 6/2/10 ;the DOH surveyor did not find a service fee schedule posted in a prominent place,at 3:00pm.
However by 3:30 on 6/2/10 a service fee schedule was posted in a prominent place.
This action was completed by the administrative Coordinator and observed by the Program Director; and the licensing surveyor before he left the facility.
The Divisional will monitor this action on an ongoing basis to ensure compliance. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on the review of client records and an interview with the facility director, the facility failed to document informed and voluntary consent for the disclosure of information contained in four of seven client records.
The findings include:
Seven client records were reviewed and an interview with the facility director was conducted on June 2, 2010. All seven records required documentation of informed and voluntary consent. The facility did not document informed and voluntary consent for the release of information contained records # 2, 3, 4 and 6.
The release forms disclosing client information to a laboratory in records # 2, 3, 4 and 6 did not include a statement informing the clients of the right to verbally revoke their consent to release the information. The facility documented that the clients must revoke the consent in writing.
Additionally, the same consent forms releasing client information to a laboratory contained language indicating the clients records could be released with verbal consent.
The Consent to Release Information form stated:
" I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written or verbal consent unless otherwise provided for in the regulations. "
|
Plan of Correction
GMCOP failed to document informed and voluntary consent of information in four of seven records reviewed in records#2#3#4and #6.And the release form disclosing information to a laboratory #2,3,4&6 did not include a statement informing the clients of ther rights to verbally revoketheir consent.THe Prog. Dir.will oversee the removal of the old forms. The approved consent forms will be received from the Corporate Office not later than 7/2/10 ,and will be added to all of the new clients charts-Action monitored by the Gaudenzia Compliance Officer. |
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 the review of client records, the facility failed to document a treatment plan in six of seven client records.
The findings include:
Seven client records were reviewed on June 2, 2010. All seven records required documentation of a treatment plan. The facility did not document a treatment plan by the third sessions, as per facility policy, in client records # 1, 2, 3, 4, 6 and 7.
The facility ' s policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" states:
"The treatment plan will be signed by the Client, the Primary Counselor, the Clinical Supervisor, physician (when applicable) and placed in the client record. Completion of the treatment plan will be noted in the counselor's progress note for that day of service, by the third session (outpatient)."
Client record #1 contained progress notes to document individual sessions on 1/5/10, 1/12/10, 3/2/10, 3/8/10 and 3/18/10, but the treatment plan was documented on 3/22/10.
Client record #2 contained progress notes to document individual sessions on 1/15/10, 1/29/10, and 2/5/10, but the treatment plan was documented on 2/12/10.
Client record #3 contained progress notes to document individual sessions on 12/14/09, 12/21/09, 12/28/09 and 1/11/10 but the treatment plan was documented on 1/13/10.
Client record #4 contained progress notes to document individual sessions on 1/4/10, 1/11/10 and 1/25/10, but the treatment plan was documented on 2/1/10.
Client record #6 contained progress notes to document individual sessions on 12/15/09, 12/21/09, 12/28/09 and 1/4/10, but the treatment plan was documented on 1/11/10.
Client record #7 contained progress notes to document individual sessions on 7/27/09, 8/3/09, 8/12/09 and 8/26/09, but the treatment plan was documented on 9/16/09.
|
Plan of Correction
GMCOP failed to document the completion of the Treatment Plan by the third session in 6 of the 7 client records that were reviewed 6/2/10.Clinical supervisor will hold a seminar with the clinical staff on 7/8/10- to explain the necessity of completing the client's Comprehensive treatment Plan by the third individual session.Client's charts will audited by the Clinical supervisor the 1st week of every month at least five per counselor; and will be randomly monotored by Prog. Dir ongoing by the 2nd wk of each Month.. |
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 the review of client records, the facility failed to document a treatment plan update in six of seven client records.
The findings include:
Seven client records were reviewed on June 2, 2010. All seven records required documentation of a treatment plan update. The facility did not document a treatment plan update, as per facility policy, in client records # 2, 3, 4, 5, 6 and 7.
The facility ' s policy titled "TREATMENT & REHABILITATION PLAN" states:
" Gaudenzia, Inc. Outpatient, will ensure treatment and rehabilitation plans will be reviewed and updated at least every sixty days. The treatment plan update will include an assessment of the client ' s progress in relationship to stated goals. "
In client record #2, the treatment plan update documented on 4/12/10 did not include an assessment of progress.
In client record #3, the treatment plan updates documented on 4/15/10 and 5/6/10 did not include an assessment of progress.
In client record #4, the treatment plan update documented on 4/1/10 did not include an assessment of progress.
In client record #5, the treatment plan update documented on 3/8/10 did not include an assessment of progress.
In client record #6, the treatment plan update documented on 3/18/10 did not include an assessment of progress.
In client record # 7, the treatment plan updates documented on 1/11/10 and 3/11/10 did not include an assessment of progress.
|
Plan of Correction
GMCOP failed to meet the standard of documenting the client's progress in relationship to the client's goals on the client's treatment Plan Update in 6 of the 7 charts reviewed on 6/2/10. The clinical supervisor will hold a seminar 7/15/10 stating the importance of documenting the clients progress in relationship to stated goals on their treatment Plan Update. The clinical Supervisor will review client charts the 1st week of every month for compliance. The Prog.Dir. will review the clients charts by the 2nd week of evry month to ensure compliance to this requirement. |