INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 18, 2011 licensure renewal inspection. The follow-up inspection was conducted on
November 16, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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 fire drill records, the facility failed to maintain a written fire drill record that included documentation of the problems encountered.
The findings include:
Fire drill records were reviewed on November 16, 2011. The records were reviewed from the period covering June 2011 to October 2011. The facility did not have documentation for problems encountered at the time of the drill, in five of five months reviewed, specifically, June 10, 2011; July 8, 2011; July 9, 2011; July 14, 2011; August 15, 2011; August 16, 2011; August 31, 2011; September 16, 2011; September 24, 2011; September 29, 2011; October 3, 2011; October 5, 2011; and October 22, 2011.
The findings were confirmed during an ongoing dialogue with the program supervisor on November 16, 2011 from approximately 2:02 P.M. to 2:05 P.M.
This is a repeat citation. The facility was cited on May 18, 201 for noncompliance with this standard.
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Plan of Correction
On November 16, 2011, the Gaudenzia CQI manager was notified that the new fire drill log did not meet licensing standards. A column needs to be added to document any problems encountered during the drill. Until the form is updated, administrative staff have been directed to access each drill and document whether there were problems or not under the comments section listed at the bottom of the drill grid. The Administrative Coordinator will be responsible for overseeing that the fire drill record includes documentation of problems encountered during each drill.
Should the system not be operative or any problems documentated, 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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709.92(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 a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan.
The findings include:
On November 16, 2011, six client records requiring documentation of short-term and long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in four of six records reviewed, specifically, client records # 1, 2, 3, and 4.
Client # 1 was admitted September 15, 2011. The individual treatment and rehabilitation plan was completed on September 19, 2011, but it did not include documentation of the long-term goals for treatment as of November 16, 2011.
Client # 2 was admitted September 13, 2011. The individual treatment and rehabilitation plan was completed on September 13, 2011, but it did not include documentation of the long-term goals for treatment as of November 16, 2011.
Client # 3 was admitted August 4, 2011. The individual treatment and rehabilitation plan was completed on September 1, 2011, but it did not include documentation of the long-term goals for treatment as of November 16, 2011.
Client # 4 was admitted August 23, 2011. The individual treatment and rehabilitation plan was completed on August 23, 2011, but it did not include documentation of the long-term goals for treatment as of November 16, 2011.
The findings were confirmed during an ongoing dialogue with the program supervisor on November 16, 2011 from approximately 2:30 P.M. to 3:00 P.M.
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Plan of Correction
An in service was held during the all staff meeting on November 18, 2011 to refresh clinical staff on treatment management procedures specific to the treatment planning process. All clinical staff were reminded to document under the goals section both a long term and short term goal. Examples of each goal were discussed by the Program Supervisor. The Program Supervisor will monitor all treatment plans for these goals. The Program Supervisor will not sign any treatment plan that does not meet this regulation.
The Program Supervisor as well as the Division Director will review for compliancy during the monthly Administrative meetings. In addition, the Division Director will randomly review charts to ensure compliancy.
Clinical staff will also be monitored through the monthly CQI process and supervisory sessions.
Any failure to comply with this standard will result in corrective action.
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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 client records, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan.
The findings include:
On November 16, 2011, six client records requiring documentation of the proposed type of support services in the individual treatment and rehabilitation plans were reviewed. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in four of six records reviewed, specifically, client records # 1, 4, 5, and 6.
Client # 1 was admitted September 15, 2011. The individual treatment and rehabilitation plan was completed on September 19, 2011, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 16, 2011.
Client # 4 was admitted August 23, 2011. The individual treatment and rehabilitation plan was completed on August 23, 2011, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 16, 2011.
Client # 5 was admitted August 2, 2011. The individual treatment and rehabilitation plan was completed on August 15, 2011, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 16, 2011.
Client # 6 was admitted September 14, 2011. The individual treatment and rehabilitation plan was completed on September 14, 2011, but it did not include documentation of the proposed type of support services in the individual treatment and rehabilitation plan as of November 16, 2011.
The findings were confirmed during an ongoing dialogue with the program supervisor on November 16, 2011 from approximately 2:30 P.M. to 3:00 P.M.
This is a repeat citation. The facility was cited on May 18, 2011 for noncompliance with this standard.
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Plan of Correction
An additional in-service training was held on November 18, 2011, during all staff meeting by the Program Supervisor to review the treatment management procedures specific to the treatment planning process. An re-emphasis was placed on every treatment plan listing support services a client needs to aid in the recovery process. A list of all possible support services was again provided to the staff and reviewed by the Program Supervisor. The Program Supervisor will monitor all treatment plans for these support services. The Program Supervisor will not sign any treatment plan that does not meet this regulation.
The Program Supervisor as well as the Division Director will review for compliancy during the monthly Administrative meetings. In addition, the Division Director will randomly review charts to ensure compliancy.
Clinical staff will also be monitored through the monthly CQI process and supervisory sessions.
Any failure to comply with this standard will result in corrective action.
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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 a review of client records, the facility failed to document a treatment and
rehabilitation plan update.
Also, based on a review of client records, the facility failed to document a treatment and rehabilitation plan update in accordance with their policy and procedures.
The findings include:
The facility's policy titled: "Treatment Plan Reviews," stated:
"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."
On November 16, 2011, six client records requiring documentation of a treatment and rehabilitation plans were reviewed. The facility did not document a treatment and rehabilitation plan update in one of six records reviewed, specifically, client record # 2. The facility also did not document a treatment and rehabilitation plan update according to their policy and procedures in one of six records reviewed, specifically, client record # 3.
Client # 2 was admitted September 13, 2011 and the individual treatment and rehabilitation plan was completed on September 13, 2011. The treatment plan update was due November 12, 2011; however, client record # 2 did not include documentation of a treatment plan update as of November 16, 2011.
Client # 3 was admitted August 4, 2011 and the individual treatment and rehabilitation plan was completed on September 1, 2011. The treatment plan update was due October 31, 2011 but the treatment plan update was not documented until November 2, 2011.
The findings were confirmed during an ongoing dialogue with the program supervisor on November 16, 2011 from approximately 2:30 P.M. to 3:00 P.M.
This is a repeat citation. The facility was cited on May 18, 2011 for noncompliance with this standard.
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Plan of Correction
An in-service training was held on November 18, 2011, to address clinical staff on treatment management procedures specific to the treatment planning process. All clinical staff were reminded to complete the initial treatment plan within 14 days of admission and updated treatment plans every sixty days or sooner. Initial treatment plans and treatment plan updates will be signed by the primary counselor and reviewed by the Program Supervisor to ensure timeliness. Program Supervisor will only sign a document 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. The CQI scores and specific counselor ratings will be compared monthly for any non-compliance issues as related to the treatment plan process. A pattern of re-occurring low scores under this category will warrant corrective action for the clinician.
Clinical staff will be monitored in regular supervisory sessions.
A treatment plan update has been completed on client record # 2 following the in-service training on 11-18-11.
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