INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 10 - 11, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Kindred House 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 15, 2010.
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Plan of Correction
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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 and a review of the policy and procedures manual, the facility failed to provide documentation of individual training plans in five of six personnel records reviewed.
The findings include:
Six personnel records were reviewed on May 10 - 13, 2010.
Individual training plans were required in five personnel records.
The facility did not document individual training plans per policy in personnel records # 1, 2, 4, 5, and 6 for the training year from January 1 2009 to December 31 2009.
The facilities policy states:
The Project Director, Program/Clinical Supervisor and/or nurse will provide each clinical, medical, administrative, and support staff member with an individual staff assessment and training plan for completion relative to the new training year.
Each individual training plan should include the staff member's perceived needs, the supervisor's recommendations, and the specific training areas of focus to be pursued, as well as targeted time frames and sources of training. It is the responsibility of the staff member to carryout the agreed upon training plan.
The individual training plan is reviewed and revised annually by the staff member and their supervisor to ensure the training needs are being addressed and met. The employee and the supervisor should each sign the plan.
The plan should be appropriate to the employee's skill level, position and performance requirements and interests. The employee's previous education and experience should also be considered in plan development.
Each plan should identify at least three subject areas for training based on areas needing improvement or goals to be pursued by the employee. It is recommended that, subject areas relate to the core staff training requirements established under Standard 704.1l. d-g, depending on the employee's job title.
Personnel # 1 was hired in 1988.
An individual training plan was documented late on 4/28/10.
Personnel # 2 was hired October 19, 2009.
An individual training plan was complete, but did not include a completion date.
Therefore, it was unable to be determined when the training plan was complete.
Personnel # 4 was hired July 1, 2009.
An individual training plan was not documented for the 2010 training year at the time of review.
Personnel # 5 was hired April 29, 2009.
An individual training plan was not documented for the 2010 training year at the time of review.
Personnel # 6 was hired November 10, 2008.
An individual training plan was not documented for the 2010 training year at the time of review.
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Plan of Correction
According to policy and procedure manual the facilty will implement a check and balance system to ensure that training plans are being developed for each employee training period. Supervisors will meet with employees on a quarterly basis to ensure staff are completeing documentation needed for the next calendar year. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of the facilities training files it was determined that the counselor assistant did not have the minimum training hours for the annual training year.
The findings include:
A review of the counselor assistant's training file revealed that the required thirty clock hours of training annually was not complete.
The counselor assistant only completed five training hours for the 2009 training year.
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Plan of Correction
The facility will ensure that the counselor assistant will have the minimun training hours that is expected of her. Counselor assistant will continue her education and attend training courses available through the training assistant. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the physical plant tour conducted on May 11, 2010 and an interview with the facility director on May 11, 2010, the facility failed to ensure that there were no heaters that were not permanently mounted or installed located in within the facility.
The findings include:
The counselor's office located adjacent to the living room/group room had a heater that was not permanently mounted or installed.
The facility director confirmed that the counselor's office had a portable space heater.
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Plan of Correction
The clinical staff and remainding were informed of the policy in reference to portable heaters. The staff are instruced to remove heaters from offices. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant tour the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room.
The findings include:
A physical plant tour was conducted on May 11, 2010.
During the tour it was observed that the exterior window of the clinical supervisors office lacked proper window treatment to ensure that counseling sessions could not be seen outside the counseling room .
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Plan of Correction
The window treatment for the office was replaced to ensure that it doesn't fall down. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client medical records, a review of the policy and procedures manual, and an interview with the facility director, the facility failed to document physical examinations per facility policy in five of seven client records.
The findings include:
Seven client medical records were reviewed on May 10 - 11, 2010 and an interview with the facility director was conducted on May 11, 2010.
All records reviewed required a physical examination.
The facility failed to document physical examinations per policy in client records # 1, 2, 3, 4, and 7.
Facility policy states:
Residents shall have a physical examination performed within the first week of admission. The physical examination will assure that a client is free from communicable diseases or any other medically related concern that would pose a significant obstacle to treatment. In cases where a client has received a verifiable physical examination within one month prior to admission, the program Medical Director or his/her designee shall perform an examination comprised of taking and recording of vital signs and asking the client if significant changes have occurred since his/her last exam.
Client # 1 was admitted to the program on 4/5/10.
The physical examination reviewed in the medical record was dated and signed by a nurse on 4/5/10.
The physical examination was timely, however, a review of the organ systems and the physician's impressions/diagnosis was not included in the
physical examination at the time of review on 5/11/10.
Client # 2 was admitted to the program on 3/10/10.
The physical examination reviewed in the medical record was dated and signed by a nurse on 3/11/10.
The physical examination was timely, however, the physician's impressions/diagnosis was not included in the physical examination at the time of review on 5/11/10.
Client # 3 was admitted to the program on 1/11/10.
The physical examination reviewed in the medical record was dated and signed by a nurse on 1/15/10.
The physical examination was timely, however, the physician's impressions/diagnosis was not included in the physical examination at the time of review on 5/11/10.
Client # 4 was admitted to the program on 9/29/09.
The physical examination reviewed in the medical record was dated and signed by a nurse on 9/29/09.
The physical examination was timely, however, the physician's impressions/diagnosis was not included in the physical examination at the time of review on 5/11/10.
Client # 7 was admitted to the program on 7/31/09.
The physical examination reviewed in the medical record was dated and signed by a nurse on 8/10/09.
The physical examination was documented late, and the physician's impressions/diagnosis was not included in the physical examination at the time of review on 5/11/10.
An interview with the facility director confirmed that the physician does not complete examinations for pregnant clients as the physicals are done by a mobile nurse team.
This is a repeat deficiency from the May 20, 2009 and June 20, 2008 inspections.
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Plan of Correction
The medical director of the organization will follow-up with outside agencies to assist with getting physicals for the women. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records and a review of the policies and procedures, the facility failed to document treatment and rehabilitation plan updates at least every 30 days in two of seven client records reviewed.
The findings include:
Seven client records were reviewed on May 10 - 11, 2010. All seven records reviewed required treatment plan updates every thirty days per facility policy.
The facility failed to document a treatment and rehabilitation update per policy in client records # 1, and 4.
The facility's policy states:
Treatment Plan Reviews: 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.
Client # 1 was admitted to the program on 4/5/10.
The comprehensive treatment plan was documented on 4/8/10.
The treatment plan update was due 5/8/10.
The treatment plan update was not documented at the time of review on 5/11/10.
Client # 4 was admitted to the program on 9/29/09.
The comprehensive treatment plan was documented on 10/2/09.
The treatment plan update was due 11/2/09.
The treatment plan update was not documented at the time of review on 5/11/10.
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Plan of Correction
Clinical Supervisor will conduct weekly supervision of counselors charts to go over monthly treatment plans. Clinical Supervisor will check the client treatment plans every thirty days. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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:
(3) Record of services provided.
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Observations
Based on a review of client records and a review of the policy and procedures manual , the facility failed to document a complete record of service in three of seven client records reviewed.
The findings include:
Seven client records were reviewed on May 10 - 11, 2010.
All records reviewed required a complete record of services provided.
The facility failed to document a complete record of services provided in client records # 1, 2, and 4.
The facilities policy states:
3.Record of Services: All services rendered to a client shall be documented on the Record of Services form, which is maintained in the client record. The form should initially be completed with the intake paperwork. The Counselor or staff person scheduled to provide a service shall record the date a service is scheduled to be provided, the specific service and the initials of the staff responsible for the service. Documentation of this should be made promptly after the appointment is scheduled. The client's attendance status and the duration of the service shall be noted as soon as the disposition is known. A ROS is completed daily.
Client # 1 was admitted to the program on 4/5/10.
The facility failed to document a complete record of services provided.
At the time of review on 5/11/10 the facility only documented on the record of service the dates 4/24/09 and 4/25/09 for services provided. Progress notes showed that there were more sessions than recorded.
Client # 2 was admitted to the program on 3/10/10 and discharged on .
The facility failed to document a complete record of services provided.
At the time of review on 5/11/10 the facility only documented on the record of service the dates 3/13/10 and 3/14/10 for services provided.
Progress notes showed that there were more sessions than recorded.
Client # 4 was admitted to the program on 9/29/09 and discharged on 12/7/09, the last date of counseling (progress note) was on 11/24/09.
The facility failed to document a complete record of services provided.
At the time of review on 5/11/10 the facility documented on the record of service the dates 12/6/09, 12/5/09, 11/29/09, 11/28/09, 11/15/09, 11/14/09, 11/8/09, 11/7/09, 10/31/09, 10/17/09, 10/10/09, 9/22/09, 9/21/09 for services provided.
Progress notes showed that there were more sessions than recorded.
There were were actually twice the amount of progress notes than documented in the record of service.
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Plan of Correction
To ensure that record of service are complete in the charts counselors will take the last hour of each work day to ensure that all services provided by the organization and outside services are documentated on the record of services. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and a review of the policy and procedures manual, the facility failed to document an aftercare plan per policy in two of seven records.
The findings include:
Seven client records were reviewed on May 10 - 11, 2010.
Three records required an aftercare plan.
The facility failed to document an aftercare plan per facility policy in client records # 4 and 6.
The facilities policy states:
18.Aftercare: After care planning is initiated the first week of admission. During the last two sessions of treatment, the Counselor will assist the client to identify goals and action steps for continuing recovery growth post treatment. The client's plan for support group attendance and any further treatment referrals should also be noted. The plan should be copied for the client's use and the signed original maintained in the record be legible.
Client # 4 was admitted to the program on 9/29/09 and discharged on 12/7/09.
The facility documented an aftercare plan on 11/24/09; however it failed to include a contact person and the reentry process.
On the aftercare form there is a question which states:
Have you been made aware of the criteria for readmission.
Client # 4 checked off NO.
Client # 6 was admitted to the program on 6/10/09 and discharged on 12/8/09.
The facility documented with date only on 6/11/09 an aftercare plan; however the form was incomplete, other than the date, at the time of review on May 11, 2010.
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Plan of Correction
Clinical team will continue to begin the aftercare process in the initial phase of treatment. Counselors will continue to work on the document and read the document with clients to ensure that all information needed is correct and complete. Aftercare plans will be reviewed by clinical supervisor to ensure they are correct and complete. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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
Freeman, Sabrina E.
Based on a review of client records and on a review of the policy and procedures manual, the facility failed to document follow-up within 7 days in two of four client records.
The findings include:
Seven client records were reviewed on May 10 - 11, 2010. Four client records required documentation of follow-up information. The facility did not document follow-up information within 7 days from the date of discharge, as per facility policy, in client records # 4, and 7.
The facility's policy states:
20. 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 directly by the counselor or supervisor ' s designee to determine the client ' s well-being and to maintain the opportunity for re-admission 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.
Client # 4 was admitted to the program on 9/29/09 and discharged on 12/7/09, follow-up was not documented at the time of review on 5/11/10.
Client # 7 was admitted to the program on 7/31/09 and discharged on 4/20/10, follow-up was not documented at the time of review on 5/11/10.
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Plan of Correction
To ensure that the facility appropriatley adheres to the policy of Gaudenzia. The intake/aftercare worker will make the inital contact of client upon discharge and document within the follow-up log. |