INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 22, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel and training records, the facility failed to provide documentation of HIV/AIDS in one of two of applicable records reviewed.
The findings include:
Two personnel records which required documentation of mandatory communicable disease training were reviewed on May 22, 2015. The facility failed to provide documentation of HIV/AIDS training for employee #2.
Employee #2 was hired 8/12/2013 as a counselor. This employee was required to obtain six hours of HIV/AIDS by 8/12/2014. A Certificate of Completion was provided by the facility for Employee #2 dated 5/15/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A certificate of completion for HIV/AIDS for employee #2 has been obtained effective 5/15/2015.
Effective immediately, the Program Director and/or Program Supervisor will ensure that mandatory trainings are completed for all new hires within 365 days of hire.
Monthly training reports will be conducted with the Administrative Manager, by the Program Director, to ensure compliance with staff training requirements. Staff trainings will be scheduled as needed per outcome of the report.
The Program Director will maintain oversight of this compliance. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in three of five client records.
The findings include:
Eleven client records were reviewed on May 22, 2015. Seven of the eleven client records reviewed were that of discharged clients. Five of the discharged clients were involuntarily terminated from treatment. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in client records, #4, #5 and #6.
Client #4 was admitted into treatment on June 16, 2014 and was involuntarily terminated from the project on December 10, 2014. There was no documentation of a written notification provided to the client as of the date of the licensing inspection.
Client #5 was admitted into treatment on July 24, 2014 and was involuntarily terminated from the project on February 6, 2015. There was no documentation of a written notification provided to the client as of the date of the licensing inspection.
Client #6 was admitted into treatment on October 21, 2014 and was involuntarily terminated from the project on March 16, 2015. There was no documentation of a written notification provided to the client as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Termination notices for being terminated involuntarily, in client files #4, #5 and #6 will be completed by June 12, 2015.
Effectively immediately, the Program/Clinical Supervisor will ensure that treatment termination notices are mailed out to clients when they have been terminated involuntarily within seven days of discharge.
Monthly chart audits will be conducted by the supervisor(s) and outcomes discussed in weekly clinical meetings or supervisory sessions, which occur quarterly, at a minimum.
The Program Director will maintain oversight of this compliance. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in six of eleven client records reviewed.
The findings include:
Eleven client records were reviewed for counseling services on 5/22/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 2, 4, 5, 6, 8, and 11.
Client #2 was admitted to treatment on 8/28/2014. Client record #2 contained a treatment plan dated 8/28/2014 and 9/17/2014 that identified the counseling services to be provided as individual therapy session 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 9/2/2014, 9/8/2014, 9/29/2014 or the month of October, 2014.
Client #4 was admitted to treatment 6/16/2014. Client record # 4 contained a treatment plan dated 8/12/14 and 9/25/14 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 9/8/2014, 9/15/2014, 9/22/2014, 9/29/2014, 10/27/2014, 11/10/2014 and 11/17/2014.
Client #5 was admitted to treatment on 7/24/2014.Client record # 5 contained a treatment plan dated 7/24/2014 and 9/4/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 8/4/2014, 8/11/2014, 8/18/2014, 8/25/2014, 9/8/2014, and 9/15/2014.
Client #6 was admitted to treatment on 10/21/2014. Client record # 6 contained a treatment plan dated 10/21/2014 and 12/22/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 11/3/2014, 11/10/2014, 11/24/2014, 1/12/2015, 1/19/2015, and 1/26/2015.
Client #8 was admitted to treatment on 12/6/2014. Client record # 8 contained a treatment plan dated 12/6/2014 and 2/28/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 2/2/2015, 2/9/2015, 2/16/2015, 2/23/2015, 4/20/2015, and 4/27/2015.
Client #11 was admitted to treatment on 2/10/2015. Client record # 11 contained a treatment plan dated 2/10/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the weeks of 3/16/2015, 4/6/2015, 4/13/2015, 4/20/2015 and 4/27/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan updates for client files #2, #4, #5, #6, #8 and #11 will indicate the appropriate identified counseling services that are to be provided by June 30, 2015.
Effective immediately, the Program/Clinical Supervisor(s) will ensure that the prescribed services(i.e., (1) individual counseling session per week or biweekly) that are being recommended are provided and documented in the treatment plan and subsequent Client Record of Services.
QI chart audits will also be conducted on a monthly basis and outcome reviews will be made with each clinician following the week of the CQI meeting.
The Program Director will be responsible for oversight of compliance with the above standards. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to ensure that a complete record was documented in four of eleven client records reviewed.
The findings include:
Eleven client records were reviewed for documentation of a complete client record during the renewal inspection on 5/22/2015. The facility failed to document the following:
Client # 6 was readmitted on 10/21/2014 and an updated consent to treatment form was not documented as of the date of the licensing inspection.
Client #9 was admitted on 2/6/32015 and the consent to treatment form was not documented as of the date of the licensing inspection.
Client # 8 was admitted on 12/6/2014 and as of the date of the licensing inspection the following months record of service was missing; February and April, 2015. Additionally, the facility failed to develop an individual treatment and rehabilitation plan for client #8 as of the date of the licensing inspection.
Client # 11 was admitted on 2/10/2015 and as of the date of the licensing inspection the following months record of services was missing; March and April, 2015. Additionally, the facility failed to develop an individual treatment and rehabilitation plan for Client #11 as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Consent to Treatment Form for client files # 6 and #9 will be completed with the client by June 30, 2015 or their next individual session, whichever occurs first.
Effective immediately, client evaluation and admission packets will include the Consent to Treatment form and will be signed within their first appointment session.
Monthly chart audits will be conducted by the Program/Clinical Supervisor(s) to ensure compliance and outcomes will be discussed with the clinicians in weekly clinical meetings and/or supervisory sessions, quarterly at a minimum.
The Record of Services and Initial Treatment Plans for client files #8 and #11 will be completed and entered into the client records by June 30, 2015 or their next session, whichever occurs first.
Effective immediately, the Client Record of Services will be filed in the client's charts by the beginning of the following month.
The consent to treatment forms, the treatment plans and record of services will be monitored via monthly QI chart audits and outcomes will be reviewed with the clinicians in the following weeks clinical meetings and/or supervisory session with the Program/Clinical Supervisor(s).
Oversight of compliance with the above standards will be maintained by the Program Director. |