INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2011 through May 19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records and a discussion with the virtual learning manager, the facility failed to ensure each clinical supervisor complete at least 12 clock hours of training annually.
The findings include:
The facility's annual training year runs from January 1st to December 31st. Annual training hours were reviewed for the facility's 1/11/10 through 12/31/10 training year.
Nine personnel records were reviewed at the facility's corporate office on May 9, 2011 through May 11, 2011. One of the nine personnel records reviewed was that of a clinical supervisor. Personnel record #3 was that of a clinical supervisor and only had documentation of 3 training hours for the facility's 2010 training year.
These findings were confirmed by the virtual learning manager.
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Plan of Correction
A review of the on location records pertaining to West Shores Program Supervisor's training hours for 1/11/10-12/31/10 was conducted on May 19, 2011 by the Division Director, Program Supervisor and the Administrative Coordinator. It was concluded that the Program Supervisor had the required number of training hours for the calendar year in question.
On June 17, 2011, the Administrative Coordinator will fax all Program Supervisors 2010 training hours and certificates to The Gaudenzia Training Institute located in Norristown, PA. The fax cover sheet will state exactly what is being sent. Upon completion of fax, the confirmation sheet will be attached to the sent documents. The Administrative Coordinator will then follow up with both a phone call and an email to the virtual learning manager asking for receipt confirmation within 24 hours of being sent. If confirmation is not received within the asked time period, the Administrative Coordinator will send a second email and copy the facility Division Director. Should the information not be confirmed, the Division Director will immediately seek corrective action through the Central Region Director.
A review of all staff training hours and completion is part of the weekly administrative meeting.
For the 2011 and future years, the above procedure will apply.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and a discussion with the virtual learning manager, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in six of nine personnel records.
The findings include:
Nine personnel records were reviewed at the facility's corporate office on May 9, 2011 through May 11, 2011. As of May 11, 2011, there was no documentation of fire extinguisher training in personnel records #4, 5, 6, 7, 8 and 9.
These findings were confirmed with the virtual learning manager.
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Plan of Correction
A review of the on location records pertaining to West Shore's staff conducted on May 19, 2011 by the Division Director, Program Supervisor and the Administrative Coordinator revealed that all staff had been adequately instructed in fire safety within their first 40 hours of employment with Gaudenzia.
An all staff in service Fire Safety training will be scheduled by the Administrative Coordinator for the next all staff meeting to occur on July 29, 2011. Fire Protection and Equipment of Carlisle will be scheduled to present. All present will sign a completion certificate representing a competency in operating a fire extinguisher. This will be a mandatory training. Failure to attend will result in corrective action.
Immediately following the in service training, the administrative coordinator will fax the completion certificate to The Gaudenzia Training Institute. The fax sheet will state exactly what is being sent with the staff names listed on the front sheet. Upon completion of the fax, the confirmation sheet will be stapled to the Fire Safety Certificate. The Administrative Coordinator will follow up with both and email and a phone call to the virtual learning manager asking for receipt confirmation within 24 hours of being sent. If the A.C. does not receive confirmation, she will follow up with a second email and copy the facility Division Director.
Should the information not be confirmed within the requested time frame, the Division Director will immediately seek corrective action through the Central Region Director.
The Certificate and fax confirmation will be reviewed by the Division Director in the weekly administrative meeting on August 2, 2011.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and a discussion with the virtual learning manager, the facility failed to ensure all staff are trained to perform assigned tasks during emergencies in six of nine personnel records.
The findings include:
Nine personnel records were reviewed at the facility's corporate office on May 9, 2011 through May 11, 2011. As of May 11, 2011, there was no documentation that staff were trained to perform assigned tasks during emergencies in personnel records #4, 5, 6, 7, 8 and 9.
These findings were confirmed with the virtual training manager.
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Plan of Correction
An all staff in service Fire Safety training will be scheduled by the facility Administrative Coordinator for the next all staff meeting to occur on July 29, 2011. Fire Protection and Equipment of Carlisle will be scheduled to present. All participants will sign a certificate representing a competency in performing assigned fire emergency tasks. All tasks will be reviewed during the presentation by the Program Supervisor and the Fire Protection employee. Staff will be allotted time to ask relevant emergency questions. This is a mandatory training. Failure to attend will result in corrective action.
Immediately following the training, the Administrative Coordinator will fax the completion certificate to the Gaudenzia Training Institute. The fax sheet will state exactly what is being sent with staff names listed on the front sheet. The confirmation sheet will be stapled to the completed certificate. The Administrative Coordinator will follow up immediately with both a phone call and an email to the virtual learning manager asking for receipt confirmation within 24 hours. If the A.C. does not receive confirmation, she will follow up with a second email request and copy the Division Director. Should the information not be confirmed within the requested time frame, the Division Director will immediately seek corrective action through the Central Region Director.
The certificate and fax confirmation will be reviewed by the Division Director in the weekly administrative meeting on August 2, 2011.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill record and a discussion with the office manager and the clinical supervisor, the facility failed to maintain a written fire drill record to include whether the fire alarm or smoke detector was operative.
The findings include:
Fire drill records were reviewed on May 18, 2011 and May 19, 2011. The fire drill record presented did not include documentation of whether the fire alarm or smoke detector was operative.
A discussion with the office manager and the clinical supervisor confirmed these findings.
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Plan of Correction
Effective May 31, 2011, the Gaudenzia CQI manager, implemented a new fire drill log which added the column to include whether the fire alarm/detector was operative or not.
Administrative staff has been directed to check the column accordingly. Should the system not be operative, the administrative staff on duty will notify immediately the Division Director, the property maintenance manager, the alarm company and all staff on duty.
The fire drill log will be reviewed monthly for accuracy at the administrative meeting. Failure to comply will result in corrective action.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative materials and a discussion with the office manager and the clinical supervisor, the facility failed to have a written letter of agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The findings include:
Letters of agreement were presented and reviewed on May 18, 2011. A written letter of agreement for 24 hour emergency medical coverage was not documented. During a discussion with the office manager and clinical supervisor, it was acknowledged that the facility had a letter of agreement for medical coverage, but it was not for 24 hour emergency medical coverage.
These findings were confirmed with the office manager and the clinical supervisor.
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Plan of Correction
A referral agreement was sent to Pinnacle Health asking for their hospital to provide Gaudenzia West Shore clients 24 hour emergency care if needed. A letter of agreement signed by Dr. Lewis Shaw and dated May 24, 2011 was received at the West Shore Facility. The Administrative Coordinator has filed the agreement in the appropriate binder as well as faxed the Dirvision Director a copy for her records.
During the next administrative meeting to be held on June 27, 2011, the referral agreements will be reviewed by the Administrative Coordinator, the Program Supervisor and the Division Director.
In the future, all referral agreements will be reviewed yearly to ensure compliancy.
Failure to do so will result in corrective action.
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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 the facility's policy and procedure manual, a review of client records and a discussion with the clinical supervisor, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one client record.
The findings include:
Sixteen client records were reviewed on May 18, 2011 and May 19, 2011. Eight of those sixteen records were discharged clients. Only one of the eight discharged clients was terminated involuntarily and required a written letter of termination.
According to the facility's policy titled "Policy & Procedure For Client Notification Of Termination & Client Right To Appeal Treatment Termination," Clients shall be advised in writing of the reasons for therapeutic discharge and may discuss reasons with counseling staff. A copy of the Therapeutic Discharge Notice will be maintained in the client record.
Client #16 was admitted on 9/21/10 and involuntarily terminated on 3/15/11. As of May 19, 2011, a written letter of termination was not documented in client record #16.
During a discussion with the clinical supervisor, these findings were confirmed.
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Plan of Correction
During the all staff meeting on July 29, 2011, a review of all required discharge paper work will be provided by the Program Supervisor. She shall state to all staff that a termination letter is required to be sent to the client upon discharge, whether the discharge is voluntary or involuntary. This letter will be considered as part of the discharge process/chart and will not be accepted by the Program Supervisor or the Administrative Coordinator for filing until it is complete. This will be a mandatory meeting.
Failure to attend or comply with the discharge paperwork will result in corrective action.
A review for compliance will be done monthly during the administrative meeting between the Division Director, the Program Supervisor and the Administrative Coordinator. The monthly UM report will monitor this as well.
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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 a review of the facility's policy and procedure manual, a review of client records and a discussion with the clinical supervisor, the facility failed to develop an individual treatment plan that shall include proposed types of support services in twelve of sixteen client records.
The findings include:
Sixteen client records were reviewed on May 18, 2011 and May 19, 2011. All sixteen records required an individual treatment plan that shall include proposed types of support services. Proposed types of support services were not documented on the individual treatment plan in client records #3, 4, 6, 7, 8, 9, 10, 11, 13, 14, 15 and 16.
According to the facility's policy titled "Treatment Plan," there is no reference that individual treatment plans shall include proposed types of support services.
During a discussion with the clinical supervisor, these findings were confirmed.
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Plan of Correction
On July 29, 2011, a mini in service will be held during all staff meeting by the Program Supervisor to review the treatment management procedures specific to the treatment planning process. An emphasis will be placed on every treatment plan listing support services a client needs to aid in the recovery process. A list of all possible support services shall be provided to the staff by the Program Supervisor. The Program Supervisor will monitor all treatment plans for these support services prior to her approval or signature.
The Program Supervisor as well as the Division Director will review monthly during Administrative meetings for compliancy.
Clinical staff will also be monitored through the monthly CQI process and supervisory sessions.
Failure to comply with this standard will result in corrective action. |
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 a review of the facility's policy and procedure manual, a review of client records and a discussion with the clinical supervisor, the facility failed to develop treatment plan updates at least every 60 days in five of sixteen client records. The facility also failed to document an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in three of sixteen client records.
The findings include:
Sixteen client records were reviewed on May 18, 2011 and May 19, 2011. All sixteen records required a treatment plan update.
According to the facility's policy titled, "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."
The treatment plan update was documented on the same date as that of the comprehensive
treatment plan in four of sixteen client records, #4, 10, 13 and 16.
Client #4 was admitted on 12/15/10. The comprehensive treatment plan was dated 3/2/11.
The first treatment plan update was also dated 3/2/11.
Client #10 was admitted on 11/16/10. The comprehensive treatment plan was dated
1/20/11. The first treatment plan update was also dated 1/20/11.
Client #13 was admitted on 10/26/10. The comprehensive treatment plan was dated
12/9/10. The first treatment plan update was also dated 12/9/10.
Client #16 was admitted on 9/21/10. The comprehensive treatment plan was dated 9/21/10.
The first treatment plan update was also dated 9/21/10.
The treatment plan update was missing in one of sixteen client records, #11. Client #11 was
admitted on 10, 2010. The comprehensive treatment plan was dated 10/20/10. As of May
18, 2011, a treatment plan update was not documented in client record #11.
The treatment plan update did not include an assessment of the client's progress in
relationship to the stated goals of the comprehensive treatment plan in three of sixteen client
records, #4, 14 and 15.
During a discussion with the clinical supervisor, these findings were confirmed.
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Plan of Correction
A review in service will be held during the all staff meeting on July 29, 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 their 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 updte when it meets compliancy standards.
The Program Supervisor, the Division Director and the Administrative Coordinator 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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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure manual, a review of client records and a discussion with the office manager and the clinical supervisor, the facility failed to document follow-up information in six of eight client records.
The findings include:
Sixteen client records were reviewed on May 18, 2011 and May 19, 2011. Eight of those sixteen client records were discharged records and required documentation of follow-up.
The facility's policy, titled "Follow Up Information" states: Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor.
When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor ' s designee, to follow-up the discharged client ' s progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum 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.
Follow-up was not documented in six of eight client records, #9, 10, 11, 12, 14 and 16. Follow-up was documented late, as per facility policy in the remaining two client records, #13 and 15.
Client #9 was admitted on 9/1/10 and discharged on 3/11/11. As of May 19, 2011, follow-up was not documented in client record #9.
Client #10 was admitted on 11/16/10 and discharged on 3/9/11. As of May 19, 2011, follow-up was not documented in client record #10.
Client #11 was admitted on 10/20/10 and discharged on 3/1/11. As of May 19, 2011, follow-up was not documented in client record #11.
Client #12 was admitted on 9/29/10 and discharged on 3/26/11. As of May 19, 2011, follow-up was not documented in client record #12.
Client #13 was admitted on 10/26/10 and discharged on 3/1/11. Follow-up was due by 4/1/11, but it was not documented until 5/7/11 in client record #13.
Client #14 was admitted on 12/30/10 and discharged on 3/28/11. As of May 19, 2011, follow-up was not documented in client record #14.
Client #15 was admitted on 11/9/10 and discharged on 3/23/11. Follow-up was due by 4/23/11, but it was not documented until 5/7/11 in client record #15.
Client #16 was admitted on 9/21/10 and discharged on 3/15/11. As of May 19, 2011, follow-up was not documented in client record #16.
A discussion with the office manager and the clinical supervisor confirmed these findings.
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Plan of Correction
On June 20, 2011, a meeting between the Division Director and the Program Supervisor will occur to review the new follow up procedure Gaudenzia has developed. On June 24, 2011 all staff will be directed during staff meeting by the Program Supervisor to complete client discharge follow up within 7 days of discharge. Program Supervisor will also put out expected requirements in memo format. There will be a required second follow up that is to be done within 30 days regardless of discharge or referral status.
Both follow ups will be documented on the same form. Forms will be forwarded monthly to the Administrative Coordinator, to be reviewed for accuracy and timeliness. If compliant, they will be filed in a central follow up binder. If not meeting compliancy standards, the Program Supervisor will follow up with staff for corrective action.
All follow up forms will be brought monthly to the administrative meeting for review.
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709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
" All clients are followed up after discharge.
Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form].
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
.Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals. "
The facility ' s policy and procedure manual contained a second written policy titled: " FOLLOW UP INFORMATION. " This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum 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."
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Plan of Correction
The facility's policy and procedure manual was reviewed May 9 ? 12, 2011 at Gaudenzia's Corporate Office. According to corporate guidelines, no individual facility may change any policy or form to suit facility needs. This citation regarding conflicting policies was reported to the Central Region Director and the CQI Director by the facility Division Director. The CQI Director revised the follow up policy on June 15, 2011. All Gaudenzia policies are now updated on the Gaudenzia website forms page. All updates will be discussed monthly in the CQI meeting and clarified by the CQI Director.
An in service will be held during the all staff meeting on July 29, 2011 to implement the new policy which states; the first follow up will be completed no later than 7 days of discharge on all referred clients who have given written consent. Follow ups will be completed on all other discharged clients within 30 days regardless of discharge status.
Both follow ups will be documented on the same form.
Forms will be forwarded monthly to the Administrative Coordinator to be filed in the proper follow up log/binder. All forms will be reviewed monthly during the administrative meeting with the Program Supervisor, Administrative Coordinator and the Division Director. Follow up will be discussed during both clinical meetings and supervisory sessions. Follow up will be completed by the Program Supervisors designated staff person.
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