INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20-21, 2010 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 and a plan of correction is due on October 23, 2010.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document at least 25 clock hours of training annually in one of two personnel records.
The findings include:
Nine personnel records were reviewed on September 21, 2010. Of the nine records reviewed, two were identified as counselors during the 2009 training year and required documentation of 25 clock hours of training. The facility did not document 25 hours of training during the 2009 training year in personnel record #5.
Personnel record # 5 documented only 8 hours of training for the 2009 training year.
An interview with the facility director on September 21, 2010 confirmed that personnel record #5 did not contain at least 25 hours of training for the 2009 training year.
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Plan of Correction
2009's lack of training hours cannot be corrected, however, for 2010 all staff have completed their annual training plan to include the correct amount of hours as defined by the Department of Health. Additional Administrative support staff reviewed and re-organized completed staff trainings for 2010 beginning September 24, 2010.
A training needs assessment meeting will be held on October 29, 2010 to discuss completed trainings and any needs required through the end of 2010. Any staff with deficient training hours or lacking any core required courses will be immediately scheduled for the next available offered course(s).
This process will be reviewed weekly by the Program Director and Administrative support staff to ensure compliance. |
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 the review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation in three of five client records.
The findings include:
Five client records requiring psychosocial evaluations were reviewed on September 21, 2010. The facility did not document a psychosocial evaluation within the first three sessions of the client ' s admission, as per facility policy, in client records # 2, 3 and 7.
The facility ' s policy titled " DELIVERY OF REHABILITATION CLINICAL PROCESSES & PROCEDURES - BIOPSYCHOSOCIAL " states:
"The biopsychosocial, with accompanying assessment and diagnostic summary must be completed within the first three sessions of the client's admission. "
Client record #2 contained progress notes to document individual sessions on 8/12/10, 8/19/10, 8/26/10, 9/2/10, 9/9/10, but the biopsychosocial was dated on 9/9/10.
Client record #3 contained progress notes to document individual sessions on 8/14/10, 8/28/10, 9/11/10 and 9/18/10, but the record did not contain a biopsychosocial at the time of review on 9/21/10.
Client record #7 contained progress notes to document individual sessions on 6/8/09, 7/8/10 and 8/10/10, but the record did not contain a biopsychosocial at the time of review on 9/21/10.
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Plan of Correction
An inservice will be held on October 29, 2010 to review treatment management procedures specific to the bio - psychosocial process and timelines. The evaluation appointment has been extended to 1 1/2 hours to allow for completion of the bio - psychosocial. Program Supervisor will remind all clinical staff of the importance of completing the bio - psychosocial in the alloted time frame of three sessions.
New Administrative staff has been hired as of 10-12-10. New procedures will be developed to expedite the filing system of all completed clinical documentation.
Program Supervisor as well as the Program Director will monitor compliance of the policy utilizing the monthly CQI process.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting.
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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 the review of client records and the facility's policies and procedures manual, the facility failed to document treatment plans to include long-term goals for treatment in four of six client records.
The findings include:
Six client records requiring treatment plans were reviewed on September 21, 2010. All six records required treatment plans to include short and long-term goals. The facility did not document treatment plans to include long-term goals, as per facility policy, in client records # 3, 4, 6 and 7.
Facility policy [Standard: 709.92.a.(1,2,3) Subject: Treatment Plan Dated January 2009] stated:
Gaudenzia Outpatient will ensure treatment plans include:
1.Short and long-term goals [realistic and stated in measurable terms] for treatment as formulated by both staff and from the client ' s list of issues/problems.
2.Type and frequency of treatment/rehabilitation services i.e. individual once/week, group twice/week.
3.Proposed type of support service (medical, psychiatric, psychological, economic, legal).
4.Application of the individual goals to the Discharge criteria.
5.Client ' s comments
6.Projected date of completion of goals.
In client record #3, the treatment plan documented on 8/11/10, did not include long-term goals.
In client record #4, the treatment plan documented on 3/3/10, did not include long-term goals.
In client record #6, the treatment plan documented on 7/7/10, did not include long-term goals.
In client record #7, the treatment plan documented on 6/8/10, did not include long-term goals.
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Plan of Correction
An additional inservice will be held on October 29, 2010 to review treatment management procedures specific to the treatment planning process. Emphasis will be placed on strenths and needs from the client's psychosocial history as well as the SNAP form that is completed at the time of admission. Program Supervisor will remind all clinical staff that short and long terms goals are client driven and need to be reflected on every treatment plan to include client comments and the projected date of completion. The type and frequency of treatment to be provided will be documented on every treatment plan as well as all additional support services needed to aid in the recovery process. All progress notes should reflect this as well. All potential discharges will be presented to Program Supervisor in clinical meeting to ensure that all goals have been met and client meets discharge criteria. Program Supervisor as well as the Program Director will monitor compliance of the policy utilizing the monthly CQI process.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly admnistrative meeting.
A thorough review of all staff trainings will be completed by Program Director & Adminstrative staff by 10-29-10 to ensure staff have attended the required Record Keeping training. Staff who have not completed the training will be registered for the next available training. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records and facility's policies and procedures, the facility failed to document treatment plans to include proposed types of supportive services in three of six client records.
The findings include:
Facility policy [Standard: 709.92.a.(1,2,3) Subject: Treatment Plan Dated January 2009] stated:
Gaudenzia Outpatient will ensure treatment plans include:
1.Short and long-term goals [realistic and stated in measurable terms] for treatment as formulated by both staff and from the client ' s list of issues/problems.
2.Type and frequency of treatment/rehabilitation services i.e. individual once/week, group twice/week.
3.Proposed type of support service (medical, psychiatric, psychological, economic, legal).
4.Application of the individual goals to the discharge criteria.
5.Client ' s comments
6.Projected date of completion of goals.
Four client records requiring treatment plans were reviewed on September 21, 2010. The facility did not document treatment plans to include proposed types of support services in client records # 2, 4 and 7.
In client record #2, the treatment plan documented on 9/2/10, did not include proposed types of support services.
In client record #4, the treatment plan documented on 3/3/10, did not include proposed types of support services.
In client record #7, the treatment plan documented on 6/8/10, did not include proposed types of support services.
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Plan of Correction
An additional inservice will be held on October 29,2010 to review treatment management procedures specific to the treatment planning process. Emphasis will be placed on strenths and needs from the client's psychosocial history as well as the SNAP form that is completed at the time of admission. Program Supervisor will remind all clinical staff that short and long terms goals are client driven and need to be reflected on every treatment plan to include client comments and the projected date of completion. The type and frequency of treatment to be provided will be documented on every treatment plan as well as all additional support services needed to aid in the recovery process. All progress notes should reflect this as well. All potential discharges will be presented to Program Supervisor in clinical meeting to ensure that all goals have been met and client meets discharge criteria. Program Supervisor as well as the Program Director will monitor compliance of the policy utilizing the monthly CQI process. Any developed treatment plan that is missing support services will not be approved nor signed by the Program Supervisor.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting.
A thorough review of all staff trainings will be completed by Program Director & Adminstrative staff by 10-29-10 to ensure staff have attended the required Record Keeping training. Staff who have not completed the training will be registered for the next available training.
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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 the review of client records and the facility's policies and procedures, the facility failed to document a treatment plan update in three of four client records.
The findings include:
Facility policy (Standard: 709.92.b Subject: Treatment Plan Dated January 2009) stated:
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. Treatment plan updates will be signed and dated by the primary counselor and clinical supervisor. The following issues will be considered:
Have problems or issues identified in the treatment plan been impacted through treatment?
Should goals be revised or restated?
Do strategies or action steps need modification?
Four client records requiring treatment plan updates were reviewed on September 21, 2010. The facility did not document a treatment plan update in client records # 4, 5 and 6.
In client record #4, the treatment plan updates documented on 5/12/10 and 7/6/10, did not include an assessment of the client ' s progress in relationship to stated goals.
In client record #5, the treatment plan updates documented on 5/20/10 and 7/15/10, did not include an assessment of the client ' s progress in relationship to stated goals.
In client record #6, the treatment plan was dated 7/7/10, but a treatment plan update was not documented at the time of review on 9/21/10.
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Plan of Correction
An additional inservice will be held on October 29,2010 to review treatment management procedures specific to the treatment planning process. All clinical staff will be reminded that all treatment plans will be updated every 60 days and will include an assessment of the client's progress in relationship to goals. Treatment plan updates will be signed and dated by the primary counselor as well as the Program Supervisor. Progress notes will reflect whether issues and goals have been achieved or improved and if they need to be revised or maintained.
When goals are changed, all action steps will be revised.
Program Supervisor as well as the Program Director will monitor compliance of the policy utilizing the monthly CQI process.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting.
New Administrative staff has been hired as of 10-12-10. New procedures will be developed to expedite the filing system of all completed clinical documentation.
A thorough review of all staff trainings will be completed by Program Director & Adminstrative staff by 10-29-10 to ensure staff have attended the required Record Keeping training. Staff who have not completed the training will be registered for the next available training.
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