INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document that fire extinguisher training was provided upon employment in two of three personnel records.
The findings include:
On May 25, 2011, the personnel records of three newly hired staff members were reviewed for documentation of fire extinguisher training. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 5 and 6.
Personnel #5 was hired on 5/26/10, but verification of this training was not documented until 6/24/10.
Personnel #6 was hired on 2/22/11, but verification of this training was not documented at the time of review on 5/25/11
An interview with the facility director on May 25, 2011 confirmed the findings.
This is a repeat citation.
The facility was cited on May 27, 2010 for failing to document fire extinguisher training.
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Plan of Correction
All staff will be given the fire extinguisher training during their first week of hire. All staff as of 6/17/11 have had their fire estinguisher training. Clinical Supervisor will be maintaining staff trainings and will ensure that all staff are trained and that it is properly documented. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
On May 25, 2011, the personnel records of three newly hired staff members were reviewed for documentation of training to perform assigned tasks during emergencies. The facility did not document that this training was provided upon employment in personnel records # 5 and 6.
Personnel #5 was hired on 5/26/10, but verification of this training was not documented at the time of review on 6/24/10.
Personnel #6 was hired on 2/22/11, but verification of this training was not documented until 5/25/11
An interview with the facility director on May 25, 2011 confirmed the findings.
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Plan of Correction
All staff will be given the training on fire drills and training to perform assigned tasks during emergencies. The Clinical Supervisor will be maintaining staff trainings and will ensure that all staff are trained and that it is properly documented. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of the facility ' s letters of agreement and an interview with the facility director, the facility failed to document a written letter of agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The findings include:
On May 25, 2011, the facility ' s letters of agreement were reviewed for documentation of an agreement with a licensed hospital or physician for 24-hour emergency medical coverage. The facility ' s letters of agreement did not include one for 24-hour emergency medical coverage.
An interview with the facility director on May 25, 2011 confirmed the findings.
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Plan of Correction
New letter of Agreement has been submitted to local hospital which states we will refer to them for emergency medical coverage. Currently, waiting for it to be signed and returned to Gaudenzia Coatesville. |
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:
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Observations
Based on a review of client records and an interview the facility director, the facility failed to comply with 4 Pa. Code 255.5 relating to projects and coordinating bodies: disclosure of client-oriented information in two of six client records.
The findings include:
On May 25, 2011, six client records were reviewed for documentation of informed and voluntary consent, specifically records # 1, 2, 3, 4, 5 and 6. The facility failed to obtain informed and voluntary consent from the client for the disclosure of information contained in records # 1 and 4.
Client record # 1 contained four (4) signed consent forms, but each of the consent forms were incomplete and contained only the client ' s signature. The consent forms did not include:
(1) The name of the person, agency or organization to whom disclosure was made.
(2) The specific information disclosed
(3) The purpose of disclosure
(4) A dated signature of client
(5) A dated signature of a witness
(6) An expiration date of the consent
Client record # 4 contained documentation of client information released to a Judge, but the record did not contain documentation of informed and voluntary consent from the client to disclose the information to the judge. The record contained fax transmission reports releasing " Treatment Status Reports " to the Judge on 3/23/11, 4/20/11 and 5/3/11. Additionally, progress notes stated voicemails were left for the Judge on 1/18/11 and 5/19/11.
An interview with the facility director on May 25, 2011 confirmed the findings.
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Plan of Correction
All staff have received training on Confidentiality and disclosure as of 6/21/11. Clients during orientation are educated on not signing releases unless they have read them and agree with the terms. All staff have further been trained to never have blank consents in charts or have clients sign blank consents. They have also been instructed to make sure they have notated if the client has accepted or rejected a copy. Clinical Supervisor is auditing all staff charts to ensure that staff are compliant. |
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 and an interview with the facility director, the facility failed to document treatment plan updates to include an assessment of the client ' s progress, as per facility policy, in five of five records.
The findings include:
On May 25, 2011, five client records requiring treatment plan updates were reviewed, specifically, records # 1, 2, 3, 4, and 5. The treatment plan updates did not include an assessment of progress, as per facility policy, in client records # 1, 2, 3, 4 and 5.
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. 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. "
In client record # 1, the treatment plan updates documented on 11/23/10 and 2/17/11 did not include an assessment of progress.
In client record # 2, the treatment plan update documented on 4/21/11 did not include an assessment of progress.
In client record # 3, the treatment plan update documented on 3/25/11 did not include an assessment of progress.
In client record # 4, the treatment plan updates documented on 2/8/11, 3/8/11 and 5/19/11 did not include an assessment of progress.
In client record # 5, the treatment plan updates documented on 10/1/10, 11/12/10 and 1/13/11 did not include an assessment of progress.
An interview with the facility director on May 25, 2011 confirmed the findings.
This is a repeat citation.
The facility was previously cited on May 27, 2010 and June 18, 2009 for failing to document treatment plan updates as per facility policy.
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Plan of Correction
Trainings on treatment plans have been completed as of 7/14/11. Clinical Supervisor will audit charts to ensure compliance of policy. This will include an assessment of the client's progress with the goals that have been identified on the treatment plan. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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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."
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Plan of Correction
Corporate revised their Policy and Procedure Manual to replace the old policy with new policy Standard: 709.53.a.11/709.54.c Subject: Follow up Date: June 2011. The policy now differentiates from clients referred for other services to be followed up within 7 days of referral and 30 days for clients after they have discharged from the program. |
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.
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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 May 25, 2011 the facility was again found to be out of compliance with the following standards:
1. 705.28(c)(4) - Fire Safety: Instruct staff in the use of the fire extinguisher upon staff employment.
This area of noncompliance was also identified during the licensing inspection conducted on May 27, 2010.
2. 709.92(b) - Treatment and Rehabilitation Services: Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
This area of noncompliance was also identified during the licensing inspections conducted on May 27, 2010 and June 18, 2009.
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Plan of Correction
705.28 (c) (4)All staff will be given the fire extinguisher training during their first week of hire. All staff as of 6/17/11 have had their fire extinguisher training. Clinical Supervisor will be maintaining staff trainings and will ensure that all staff are trained and that it is properly documented. We have also added an additional step to ensure that we are in compliance which is a facility check off sheet that each new hire is to complete and Clinical Supervisor will sign off on it. This will be placed in their employee file at facility.
709.92(b)- Facility was sited in 2010 for not complying with policy of required time frame of 30 days for all tx. plans. This issue was remedied on the last plan of correction. The audit on May 25, 2011 found us to be out of compliance due to not assessing progress to goals. This is the facilities plan of correction to address this compliance issue.
Trainings on treatment plans have been completed as of 7/14/11. This training includes helping staff understand how to write a proper treatment plan and how to properly assess clients progress to the goals. Clinical Supervisor is auditing charts weekly to ensure that they are completed within the required time frames and that staff are including their assessment of progress. |