INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15 - 16, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc. - Crossroads 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report forms for all of the facilities within the drug and alcohol treatment project, the project failed to have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The Staffing Requirements Facility Summary Report forms for the drug and alcohol treatment project's ten facilities were reviewed December 14 - 18, 2015. The project employs a total of 26.01 full-time counselors and counselor assistants. This number of full-time counselors and counselor assistants would require a minimum of 3 full-time clinical supervisors. The project currently employs 2 full-time clinical supervisors, as of December 18, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A current Clinical Supervisor (residential) who was carrying a caseload of clients has had the caseload removed and will carry no more than one client at any time in the future. This will increase the number of Clinical Supervisors in the project. The Program Supervisor (residential) will assure the clinical supervisor is not tasked with a case load of more than 1 client at any given time.
Division Director will also hire an additional Clinical Supervisor for the project. Division Director will also make sure that the project is in compliance moving forward.
Division Director will make sure the project will have one clinical supervisor for every 8 FTE counselors/counselor assistants. |
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, the facility failed to document an informed and voluntary consent from the client that adhered to 4 Pa. Code 255.5 in six of fourteen client records.
The findings included:
Fourteen client records were reviewed on December 15 - 16, 2015. Fourteen client records were reviewed for written, informed and voluntary consents from the client that adhered to 4 Pa. Code 255.5.
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
The facility failed to document an informed and voluntary consent from the client that adhered to 4 Pa. Code 255.5 in client records # 1, 3, 7, 8, 9 and 14.
Client # 1 was admitted into treatment on December 11, 2015. A consent to release information was documented for the probation officer on December 11, 2015. This consent listed the specific information to be released included the urine results for client # 1. The release of urine results exceeds the limitations imposed at 4 Pa. Code 255.5.
Client # 3 was admitted into treatment on November 17, 2015 and discharged on November 21, 2015. A consent to release information was documented for the probation officer on November 17, 2015. This consent listed the specific information to be released included the urine results for client # 3. The release of urine results exceeds the limitations imposed at 4 Pa. Code 255.5.
Client # 7 was admitted into treatment on October 20, 2015. A consent to release information was documented for the probation officer on October 20, 2015. This consent listed the specific information to be released included the urine results for client # 7. The release of urine results exceeds the limitations imposed at 4 Pa. Code 255.5.
Client # 8 was admitted into treatment on September 17, 2015. A consent to release information was documented for the probation officer on September 17, 2015. This consent listed the specific information to be released included the urine results for client # 8. The release of urine results exceeds the limitations imposed at 4 Pa. Code 255.5.
Client # 9 was admitted into treatment on November 17, 2015. A consent to release information was documented for the probation officer on November 17, 2015. This consent listed the specific information to be released included the urine results for client # 9. The release of urine results exceeds the limitations imposed at 4 Pa. Code 255.5.
Client # 14 was admitted into treatment on May 6, 2015 and discharged on July 15, 2015. A consent to release information was documented for the probation officer on May 6, 2015. This consent listed the specific information to be released included the urine results for client # 14. The release of urine results exceeds the limitations imposed at 4 Pa. Code 255.5.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will train and educate all staff about informed and voluntary consent forms and the items that are permitted to be released on the form:(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Informed and Voluntary Consent Forms will be reviewed monthly by the Program Director and/or Clinical Supervisor through monthly chart audits and results will be documented on monthly chart audit form. Monthly chart audit results will be reviewed in the agency monthly quality improvement meeting.
Client #1,7,8,and 9 (if still open records) will be provided with a new/corrected consent form for the probation officer.
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709.63(a) LICENSURE Client record
709.63. 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 document a complete client record on an individual which includes information relative to the client's involvement with the project in two of two detoxification client records.
The findings include:
Fourteen client records were reviewed on December 15 - 16, 2015. Four client records pertained to the detoxification activity. Three of these records were closed. Two records required documentation of follow-up information. The facility failed to document a complete client record including follow-up information in client records # 2 and 4.
Client # 2 was admitted into treatment on July 21, 2015 and discharged on July 25, 2015. There was no documentation of follow-up information in client record # 2, as of December 16, 2015.
Client # 4 was admitted into treatment on July 27, 2015 and discharged on July 31, 2015. There was no documentation of follow-up information in client record # 2, as of December 16, 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review follow-up policy with the Nurse Manager who has oversight of the detoxification unit.
Nurse Manager will review the agency follow-up policy with all detoxification staff.
Nurse Manager will monitor follow-up forms through monthly chart audits and assure that a copy of the follow-up form is completed and placed in all client records upon discharge. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual which includes information relative to the client's involvement with the project in ten of ten residential client records.
The findings include:
Fourteen client records were reviewed on December 15 - 16, 2015. Ten client records pertained to the residential activity. Ten client records were reviewed for verification that work done by the client at the project was an integral part of his/her treatment and rehabilitation plan. Five residential client records were closed. Four of these records required documentation of follow-up information. The facility failed to document work done by the client at the project was an integral part of his/her treatment plan in client records # 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14. The facility failed to document a complete client record including follow-up information in client records # 5, 13 and 14.
Client # 5 was admitted into treatment on March 16, 2015 and discharged on June 15, 2015. There was no documentation of follow-up information in client record # 5, as of December 16, 2015.
An individual treatment plan was developed with client # 5 on March 24, 2015. The facility failed to document work done by client # 5 at the project was an integral part of his/her treatment plan.
Client # 6 was admitted into treatment on November 23, 2015. An individual treatment plan was developed with client # 6 on December 9, 2015. The facility failed to document work done by client # 6 at the project was an integral part of his/her treatment plan.
Client # 7 was admitted into treatment on October 20, 2015. An individual treatment plan was developed with client # 7 on November 6, 2015. The facility failed to document work done by client # 7 at the project was an integral part of his/her treatment plan.
Client # 8 was admitted into treatment on September 17, 2015. An individual treatment plan was developed with client # 8 on October 30, 2015. The facility failed to document work done by client # 8 at the project was an integral part of his/her treatment plan.
Client # 9 was admitted into treatment on November 17, 2015. An individual treatment plan was developed with client # 9 on December 1, 2015. The facility failed to document work done by client # 9 at the project was an integral part of his/her treatment plan.
Client # 10 was admitted into treatment on September 24, 2015. An individual treatment plan was developed with client # 10 on November 5, 2015. The facility failed to document work done by client # 10 at the project was an integral part of his/her treatment plan.
Client # 11 was admitted into treatment on August 8, 2015 and discharged on September 4, 2015. An individual treatment plan was developed with client # 11 on August 25, 2015. The facility failed to document work done by client # 11 at the project was an integral part of his/her treatment plan.
Client # 12 was admitted into treatment on June 25, 2015 and discharged on September 17, 2015. An individual treatment plan was developed with client # 12 on July 28, 2015. The facility failed to document work done by client # 12 at the project was an integral part of his/her treatment plan.
Client # 13 was admitted into treatment on June 11, 2015 and discharged on September 9, 2015. There was no documentation of follow-up information in client record # 13, as of December 16, 2015.
An individual treatment plan was developed with client # 13 on July 21, 2015. The facility failed to document work done by client # 13 at the project was an integral part of his/her treatment plan.
Client # 14 was admitted into treatment on May 6, 2015 and discharged on July 15, 2015. There was no documentation of follow-up information in client record # 14, as of December 16, 2015.
An individual treatment plan was developed with client # 14 on May 11, 2015. The facility failed to document work done by client # 14 at the project was an integral part of his/her treatment plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will complete a training with all clinical staff discussing the importance of addressing work therapy in each clients treatment plan.
The Program Director/Program Supervisor/and/or the Clinical Supervisor will audit client records monthly and assure work therapy is identified and addressed in the clients record.
The Program Director will make sure the follow-up policy is reviewed with appropriate staff and that these staff are trained in how to complete the follow-up form and make sure a copy is placed in the client record.
The Program Director will assure Client chart audit results are reviewed and discussed in the agency monthly quality improvement meeting. Any continuing issues with work therapy or follow-up will be discussed in this meeting. |