INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the September 21, 2010 licensure renewal inspection. The follow-up inspection was conducted on April 21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 May 24, 2011.
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Plan of Correction
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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 an interview with the clinical supervisor, the facility failed to document a psychosocial evaluation within the first three sessions of the client's admission in seven of nine records.
The findings include:
On April 21, 2011, nine client records requiring psychosocial evaluations were reviewed, specifically records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. 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 # 1, 2, 3, 4, 5, 6 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."
In client record #1, individual counseling progress notes were documented on 1/6/11, 2/3/11 and 4/12/11, but the record did not contain a psychosocial evaluation.
In client record #2, individual counseling progress notes were documented on 1/10/11, 2/3/11 and 3/8/11, but the record did not contain a psychosocial evaluation.
In client record #3, individual counseling progress notes were documented on 1/25/11, 2/8/11 and 2/22/11, but the psychosocial evaluation was dated 3/14/11.
In client record #4, the record of services indicated the individual counseling sessions occurred on 2/28/11, 3/8/11 and 3/22/11, but the record did not contain a psychosocial evaluation (or progress notes).
In client record #5, individual counseling progress notes were documented on 1/6/11, 1/27/11 and 2/10/11, but the record did not contain a psychosocial evaluation.
In client record #6, individual counseling progress notes were documented on 12/22/10, 1/4/11 and 1/12/11, but the record did not contain a psychosocial evaluation.
In client record #7, individual counseling progress notes were documented on 12/22/10, 12/28/10 and 1/11/11, but the record did not contain a psychosocial evaluation.
An interview with the clinical supervisor on April 21, 2011 confirmed the findings.
This is a repeat citation.
The facility was cited on September 21, 2010 and May 14, 2009 for failing to document psychosocial evaluations.
In response to the citation issued on September 21, 2010, the facility's plan of correction submitted on 10/8/2010 and approved on 10/26/2010 stated the following:
"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 allotted [sic] 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."
In response to the citation issued on May 14, 2009, the facility's plan of correction submitted on 6/9/2009 and approved on 7/9/2009 stated the following:
"The Program Supervisor is responisble [sic] for training re: psychosocial evaluations on assets/strengths, coping mechanicism, [sic] support systems, and negative factors impacting treatment for all clinical personnel. This training will be documented through feedback forms through in-service and reflected on monthly reports. This improvement process will be reviewed by Program Supervisor through clinical meetings held weekly and monthly quality assurance review."
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Plan of Correction
A review in-service will be held on June 3, 2011 to refresh clinical staff on treatment management procedures specific to the bio-psychosocial process and timelines; specifically completion within three sessions. Both evaluation and admission appointments have been extended to 1 1/2 hours to allow for completion of the bio-psychosocial.
The Administrative staff consists of three full time positions all hired within the last year. Weekly administrative meetings are scheduled to review procedures and effectiveness of filing clinical documentation.
The Program Director, Program Supervisor and Clinical Supervisor will monitor the timeliness of the bio-psychosocial completion through the monthly CQI process.
Clinical staff will be monitored by the Program Supervisor in monthly supervisory sessions to include corrective action for failure to comply with standards. Compliancy will be discussed in a weekly administrative meeting. |
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:
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Observations
Based on the review of client records and an interview with the clinical supervisor, the facility failed to document an individual treatment and rehabilitation plan in six of nine records.
The findings include:
On April 21, 2011, nine client records requiring treatment and rehabilitation plans were reviewed, specifically records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. The facility did not document an individual treatment and rehabilitation plan based on information collected in client histories within the first three sessions of the client's admission, as per facility policy, in client records # 1, 2, 3, 4, 5 and 6.
The facility's policy titled "PROCEDURE FOR INDIVIDUAL TREATMENT & REHABILITATION PLAN" States:
"An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. The counselor will create, with the client, a proposed treatment plan, based on information collected in patient histories, the bio-psycho-social and assessment and the clients [sic] problem list. The plan will be discussed with the client and changes made upon client request as appropriate."
"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, within 3 days of admission (residential) or by the third session (outpatient).Chesapeake region requires an initial TP within 24 hours)."
In client record #1, individual counseling progress notes were documented on 1/6/11, 2/3/11 and 4/12/11, but the record did not contain an individual treatment plan.
In client record #2, the treatment and rehabilitation plan was completed prior to the completion of the client history. The client history was dated 3/8/11, but the individual treatment and rehabilitation plan was dated 2/5/11.
In client record #3, the treatment and rehabilitation plan was completed prior to the completion of the client history. The client history was dated 3/14/11, but the individual treatment and rehabilitation plan was dated 2/22/11.
In client record #4, the record of services stated individual counseling sessions occurred on 2/28/11, 3/8/11 and 3/22/11, but the record did not contain an individual treatment and rehabilitation plan.
In client record #5, individual counseling progress notes were documented on 1/6/11, 1/27/11 and 2/10/11, but the individual treatment and rehabilitation plan was dated 2/24/11.
In client record #6, the treatment and rehabilitation plan was completed prior to the completion of the client history. The client history was completed on 1/12/11, but the individual treatment and rehabilitation plan was dated 12/22/10.
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Plan of Correction
An in-service will be held by the Program Supervisor on June 10, 2011 to address timelines and steps required to complete the initial treatment plan. All clinicians will be directed to complete the bio-psychosocial assessment within the first three sessions. A client driven treatment plan will be completed at the end of the third session. The evaluation and admission appointment have been extended to 1 1/2 hours each to allow for completion of the bio-psychosocial and assessment. All staff will be directed that no treatment plans will be developed without referring to a completed client assessment.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply. Compliancy will be discussed in a weekly administrative meeting.
Program Supervisor and Program Director will monitor compliance utilizing the monthly CQI process.
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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 an interview with the clinical supervisor, the facility failed to document treatment plan updates to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in three of six client records.
The findings include:
On April 21, 2011, six client records requiring treatment plan updates were reviewed, specifically records # 2, 5, 6, 7, 8 and 9. The facility failed to document a treatment plan update to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in client records # 2, 6 and 7.
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?
In client record #2, the comprehensive treatment plan was dated 2/5/11, but a treatment plan update had not been completed 60 days later.
In client record #6, the comprehensive treatment plan was dated 12/25/10, but a treatment plan update had not been completed 60 days later.
In client record #7, the treatment plan update dated 2/22/11 did not include an assessment of the client ' s progress.
An interview with the clinical supervisor on April 21, 2011 confirmed the findings.
This is a repeat citation.
The facility was cited on September 21, 2010, May 12, 2010, May 14, 2009 and August 22, 2007 for failing to document treatment plan updates.
In response to the citation issued on September 21, 2010, the facility's plan of correction submitted on 10/8/10 and approved on 10/26/10 stated the following:
" 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 [sic] 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. "
In response to the citation issued on May 12, 2010, the facility's plan of correction submitted on 7/30/10 and approved on 8/2/10 stated the following:
" An inservice will be held on August 27, 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. "
In response to the citation issued on May 14, 2009, the facility's plan of correction submitted on 6/9/09 and approved on 7/9/09 stated the following:
" Timeliness of treatment plans will be reviewed in weekly supervisory session and documented by Program Supervisor in supervisory session notes. On a weekly basis, utilization of the census tool developed to monitor treatment plan timeliness will occur to identify those counselors who need to complete treatment plans and treatment plan updates for the next week. This will be documented in clinical meeting notes. Failure to do so will dictate the appropriate disciplinary action by the Program Supervisor/Division Director. "
In response to the citation issued on August 22, 2007, the facility's plan of correction submitted on 10/24/07 and approved on 11/5/07 stated the following:
" The program supervisor will use the client census in clinical meetings and supervisory sessions to determine the completion of treatment plan review every 60 days. The program supervisor will hold counselors responsible for the compliance to this standard. "
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Plan of Correction
A review in-service will be held on June 3, 2011 to refresh clinical staff on treatment management procedures specific to the treatment planning process. All clinical staff will be directed to complete their updated treatment plans every sixty days and will include an assessment of the client's progress in relationship to goals. Assessments will refer back to previous goals and discuss treatment effectiveness regarding completion or a need for revision. If goals are changed, action steps will be revised as well. Treatment plan updates will be signed by the primary counselor and reviewed by the Program Supervisor to ensure timeliness. Program Supervisor will only sign update when it meets compliancy standards.
Program Supervisor and the Program Director will monitor compliance of the policy utilizing both the monthly CQI process as well as weekly administrative meetings.
Clinical staff will be monitored in regular supervisory sessions to include corrective action for failure to comply.
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