INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10 through 11, 2012 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Gaudenzia Inc. Broad Street 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an individual training plan in accordance with facility policy in one of four records.
The findings include:
The project policy states: "In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year."
On May 9, 2012, employee # 1's personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
Employee # 1 has been the Project Director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
The findings were reviewed with the human resources staff.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employess within the required timeframes.
A reminder of the January 31st deadline for completion will be forwarded to all managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an individual training plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed individual training plan is presently in the Project Director's file. Individual Training plans will be completed for all employees by January 31st as per our policy. |
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 a review of personnel records and a review of the Staffing Requirements Facility Summary Report, it was determined that the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.
The findings include:
On May 7 - 9, 2012, three employee records requiring documentation of 25 hours of annual training were reviewed. The facility failed to ensure that two of three counselors completed the required 25 hours of training, specifically, employee # 4 and 6.
Employee # 4, a counselor, was hired 12/24/07.
Employee # 4 was required to completed 25 clock hours of annual training.
However, a review of employee # 4's personnel record only contained documentation showing 11 hours of training.
Employee # 6, a counselor, was hired in 1998.
Employee # 6 was required to complete 25 clock hours of annual training.
However, a review of employee # 6's personnel record only contained documentation showing 11 hours of training.
The Human Resource Department confirmed the findings.
This is a repeat citation. The facility was previously cited on 5/13/11.
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Plan of Correction
1. The Program Supervisor of Clinical Services will complete Individual Training Plans with each Clinical staff person by December 31st of each claendar year to total the required 25 hours for clinical staff.
2. The Program Supervisor of Clinical Services will complete the required training registration form totaling the required 25 hours for each clinician and submit to the training institute with the individualized training plan for each clinician by January 31,st of 2013.
3. The Program Supervisor will obtain the training registration confirmation for each scheduled clinician and give a copy to each clinician.
The Program Director will have the Administrative Coordinator generate a memo to each scheduled clinician as a reminder to attending upcoming trainings. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based upon observation during a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
The findings include:
On May 11, 2012 a physical plant inspection was conducted at approximately 2:30 PM.
The facility failed to keep the facility in good repair at all times.
It was observed that one out of two of the female bathrooms on the second floor had stained/water damaged ceiling tiles which were wet and heavy with water, presenting a potential hazard of the ceiling tile falling on someone, specifically the bathroom by bedroom # 1.
It was observed that two out of two showers in male bathroom # 2 had broken shower water knobs, presenting a potential hazard of getting cut, specifically the bathroom by bedroom # 4.
It was observed that one of two toilets in male bathroom # 3 was leaking. During the physical plant inspection water was observed on the floor in the bathroom, presenting a potential fall hazard. This toilet is located by bedroom # 7.
The Facility Director confirmed the findings. She also stated that the toilet on the third floor was leaking.
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Plan of Correction
1. The Program Supervisor will contact the Maintenance Department via the electronic maintenance system of the need to replace ceiling tiles.
2. The Program Supervisor will assign a house manager to inspect ceiling tiles on a nightly bases and document on a inspection log.
3. The Program Supervisor will ensure that all issues realting to safety are documented on the monthly safety report and report out tin the monthly safety committee meeting.
4. The Program Director will inspect the building monthly for safety issues, inspect the inspection log weekly and follow through with the Director of Buliding Maintenance to address all safety issues in a expedited manner.
5. The maintenance department replaced all ceiling tiles in the women's bathroomon on 5/31/2012.
6. The maintenance department replaced all showerheads and faucet knobs on 5/31/12.
7. The toilet in the 3rd floor men;s bathroom has been replaced to address the leaking in the women's bathroom on the 2nd floor. This was completed on June 26, 2012.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation during a physical plant inspection, the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
On May 11, 2012, a physical plant inspection was conducted at approximately 2:30 PM.
The facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer in the following bathrooms:
It was observed that two out of three of the male bathrooms on the third floor lacked an operable soap dispenser, bathrooms # 1 and 2.
It was observed that one out of three of the male bathrooms on the third floor lacked individual paper towels or a mechanical dryer, bathroom # 1.
The Facility Director confirmed the findings.
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Plan of Correction
1. The Program Supervisor will have the assigned agency maintenance person install wall mounted soap dispensers in each client bathroom.
2. The Program Supervisor will assign House Managers to refill all soap dispensers each night during the overnight shiftin all client bathrooms.
3. The Program Supervisor will have the assigned agency maintenance person install papertowel dispensers in each client bathroom.
4. The Program Supervisor will assign overnight staff to refill papertowel dispensers as well as soap dispensers on the overnight shift and during the day shift as needed. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based upon observation during a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
On May 11, 2012, a physical plant inspection was conducted at approximately 2:30 PM.
The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
It was observed that one out of two of the female bathrooms on the second floor had stained/water damaged ceiling tiles which were wet and heavy with water, specifically the bathroom by bedroom # 1.
It was observed that one out of two showers in male bathroom # 1 was out of order.
It was observed that two out of two showers in male bathroom # 2 had broken shower water knobs, specifically the bathroom by bedroom # 4.
It was observed that one of two toilets in male bathroom # 3 was leaking. During the physical plant inspection, water was observed on the floor in the bathroom. This leaking toilet reportedly was responsible for the water damaged ceiling tiles on the second floor ladies bathroom. This toilet is located by bedroom # 7.
The Facility Director confirmed the findings. She also stated that the toilet on the third floor was leaking.
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Plan of Correction
1. The Program Supervisor will conatct Gaudenzia assigned Maintenance person to replace ceiling tiles in the women's bathroom.
2. The Program Supervisor will enter the need for the replacing of ceiling tiles for the women's bathroom in the agency electronic manintenace system.
3. The Program Supervisor will assign a house manager staff person to complete a weekly facility maintenance and safety log to ensure ceiling tiles are replaced when needed.
The Program Director will review the facility maintenance and safety log on a weekly basis.
5. The shower in male bathroom #1 has been repaired by maintenance.
6. The showerheads and faucet knobs were repaired by maintenance on 5/31/12.
7. The toliet in male bathroom was repaired by Maintenance on 6/26/12. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director(when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"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)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
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Plan of Correction
The relevant policies of Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant Satae, Accreditation, and funding requirements. Changes to these policies will be reviewed with clinicians at each facilitie's staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Individual Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervisionas well as staff meetings and monthly CQI analysis. These policies will be revised and approved by July,31, 2012. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services by the end of the fiscal year.
The findings include:
On May 7 through May 9, 2012, the project's administrative records were reviewed for a financial audit following the end of their fiscal year. The project's fiscal year runs from July 1 through June 30. The financial audit was to be documented by the end of the fiscal year; the financial audit was documented on February 20, 2012.
Administration confirmed that the financial audit had not been documented following the end of the fiscal year; the financial audit was documented on February 20, 2012.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within the required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recoreded in the meeting minutes. The Director of Finance and accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner. The fiscal audit for Fiscal year 2011-2012 will be completed within six months after June 30, 2012 close of Gaudenzia's fiscal year December 31, 2012)as per Chapter 709.25(a). |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based upon a review of the facility's discharged client list and the client records presented to the Licensing Specialist at the time of the inspection, the facility failed to secure client records within a locked storage container.
The findings include:
On May 10, 2012, the active and discharged client lists were reviewed and a random sample of client records were selected for review. Client records for seven active clients, # 1, 2, 3, 4, 5, 6, & 7, and five discharged clients, # 8, 9, 10, 11 & 12 were selected. The facility failed to provide one out of five discharged client records requested, specifically record # 12.
The facility was unable to provide the record for review at the time of the inspection.
The facility director confirmed that the record could not be found.
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Plan of Correction
1. The Program Director has implemented a clinical Chart accountability form/sign in/sign out sheet for all clinicians and administrative staff to sign active and clinical charts in and out.
2. The Program Supervisor will audit the clinical chart room, sign in/out log and the cabinet once per week for compliance with HIPPA laws and assurance of clinical charts being in a locked cabinet as required.
3. The Program Director will review the log bi-weekly to review compliance of the above.
4. The Administrative Coordinator will develop a form to sign discharged clinical charts in and out in the Administrative Offices.
5.The Administrative Coordinator will develop a complete list of all discharged clinical charts for the fiscal year to conduct a monthly audit of all discharged clients.
6. The Program Director will review this list monthly for compliance to the sign in/out sheet.
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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 and clinical documentation, the facility failed to obtain an informed and voluntary consent in one of six client records.
The findings include:
On May 10 - 11, 2012, six client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 4 Pa. Code 255.5. The facility failed to adhere to the requirements specified at 4 Pa. Code in one of six records, specifically client record # 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.
Client # 5 was admitted to the program on 12/8/11. Three signed "Consent to Release Information" forms were documented on 12/8/11. The signed "Consent to Release Information" forms documented the release of information which exceeds the limitations of 4 Pa. Code 255.5.
The first consent to release documented the release of urinalysis, medical updates, and medication updates to a government agency.
The second consent to release documented the release of urinalysis, medical updates, and medical information to the funding source.
The third consent to release documented the release of urinalysis and progress reports to the funding source.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Administrative Coordinator will type the five following areas on the informed and voluntary consent forms in the form of a template for all clinical charts:
(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.
2. The Program Supervisor will audit clinical charts on a monthly basis to ensure that consents contain only the information to be released as required by Pa. Code 255.5.
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records and clinical documentation, the facility failed to obtain an informed and voluntary consent in one of six client records.
The findings include:
On May 10 - 11, 2012, six client records requiring documentation of an informed and voluntary consent were reviewed to ensure compliance with 28 Pa. Code 709.28 and 42 CFR Part II subpart C subsection 2.31 (b).
28 Pa. Code 709.28 states:
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:
(1) Name of the person, agency or organization to whom disclosure is made.
(2) Specific information disclosed.
(3) Purpose of disclosure.
(4) Dated signature of client or guardian.
(5) Dated signature of witness.
(6) Expiration date of the consent.
Client # 7 was admitted to the program on 1/6/12.
A signed "Consent to Release Information" form documented on 1/6/12, to a government agency, failed to indicate what information would be disclosed.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Program Director will conduct an inservice on 7/13/2012 with both Administrative Coordinators focusing on the fact that the name of the person, agency or organization for whom the dissclosure is made is to be entered on the consent to release information, the specfic information to be disclosed, the purpose of the disclosure, the date and signature of the client or the guardian and the expiration date of the consent to release form.
2.Supervisor will ensure all informed and voluntary consent forms include what information is ot be disclosed by conducting a monthly CQI audit of clinical charts.
3. The Program Director will review this information with the Recovery Specialist, Social Worker and clinical staff in the weekly Administrative Meeting on 7/13/2012. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in three of nine records reviewed.
The findings include:
On May 10 -11, 2012, nine records requiring documentation of the client's medical history were reviewed. The facility failed to document a medical history in three of nine records reviewed, specifically client records # 5, 6, and 9.
Client # 5 was admitted to the program on 12/8/11, and was still an active client.
Client record # 5 did not include a medical history at the time of review on 5/11/12.
Client # 6 was admitted to the program on 12/13/11, and was still an active client.
Client record # 6 did not include a medical history at the time of review on 5/11/12.
Client # 9 was admitted to the program on 6/8/11 and discharged on 1/26/12.
Client record # 9 did not include a medical history for the client's duration of treatment.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Program Supervisor will conduct an inservice with all clinical staff reviewing the psychosocial history, including the medical history.
2. The Program Supervisor will review and sign off on all psychosocial histories, ensuring that the medical histories are included in the document.
3. The Program Director will audit a random selection of clinical charts monthly for CQI reporting to ensure that medical histores have been completed as required. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug or alcohol history in three of nine records reviewed.
The findings include:
On May 10 -11, 2012, nine records requiring documentation of the client's drug or alcohol history were reviewed. The facility failed to document a drug or alcohol history in three of nine records reviewed, specifically client records # 5, 6, and 9.
Client # 5 was admitted to the program on 12/8/11, and was still an active client.
Client record # 5 did not include a drug or alcohol history at the time of review on 5/11/12.
Client # 6 was admitted to the program on 12/13/11, and was still an active client.
Client record # 6 did not include a drug or alcohol history at the time of review on 5/11/12.
Client # 9 was admitted to the program on 6/8/11 and discharged on 1/26/12.
Client record # 9 did not include a drug or alcohol history for the client's duration of treatment.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Program Supervisor will conduct an inservice with all clinical staff focusing on the psychosocial history and the drug amd alcohol history.
2. The Program Supervisor will review all psychosocial histories to ensure the inclusion of the drug and alcohol histories for completeness and sign off as required.
3. The Program Director will audit a random sample of clinical charts, reviewing the psychosocial histores and specifically the drug and alcohol history monthly for the CQI report as required. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history in three of nine records reviewed.
The findings include:
On May 10 -11, 2012, nine records requiring documentation of the client's personal history were reviewed. The facility failed to document a personal history in three of nine records reviewed, specifically client records # 5, 6, and 9.
Client # 5 was admitted to the program on 12/8/11, and was still an active client.
Client record # 5 did not include a personal history at the time of review on 5/11/12.
Client # 6 was admitted to the program on 12/13/11, and was still an active client.
Client record # 6 did not include a personal history at the time of review on 5/11/12.
Client # 9 was admitted to the program on 6/8/11 and discharged on 1/26/12.
Client record # 9 did not include a personal history for the client's duration of treatment.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Program Supervisor will conduct an inservice for all clinical staff focusing on the psychosocial history, particularly the area of personal histories.
2. The Program Supervisor will review all psychosocial histories focusing on the area of personal history for completeness as they are completed and sign off as required upon ensuring completeness.
3. The Program Director will audit a random sample of clinical charts on a monthly basis reviewing psychosocial histories while focusing on completeness of the personal history for CQI reporting as required. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and a review of the project's policy and procedures manual, the facility failed to document a psychosocial evaluation per policy in three of nine records reviewed.
The findings include:
The project's policy states: "The psychosocial assessment shall be submitted promptly and shall not exceed 5 treatment days after the client's admission to the program."
On May 10 - 11, 2012, nine client records requiring documentation of a psychosocial evaluation were reviewed.
The facility failed to document a psychosocial evaluation in three of nine client records reviewed, # 5, 6, and 9.
Client # 5 was admitted to the program on 12/8/11.
The psychosocial evaluation was to be documented within 5 treatment days, 12/15/11.
Client # 5's record did not contain a psychosocial evaluation at the time of review on 5/11/12.
Client # 6 was admitted to the program on 12/13/11.
The psychosocial evaluation was to be documented within 5 treatment days, 12/20/11.
Client # 6's record did not contain a psychosocial evaluation at the time of review on 5/11/12.
Client # 9 was admitted to the program on 6/8/11 and discharged on 1/26/12.
The psychosocial evaluation was to be documented within 5 treatment days, 2/2/12.
Client # 9's record did not contain a psychosocial evaluation at the time of review on 5/11/12.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Program Supervisor will review the clinical policy with all clinical staff and have each sign off on receipt of the policy.
2. The Program Supervisor will then conduct an inservice for all clinical staff focusing on the psychosocial evaluation documentation.
3.All newly hired clinical staff will be scheduled and required to attend Recordkeeping Training with the Gaudenzia Training Institute within the first 6 months of employment.
4. The Program Supervisor will review all psychosocial histories and evaluations to ensure completeness and sign off as required.
5. The Program Director will audit a random sample of clinical charts to ensure completeness of the psychsocial evaluation monthly for the required CQI reporting. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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 a review of client records and a review of the project's policy and procedures manual, the facility failed to document an individualized treatment and rehabilitation plan per policy in three of nine records reviewed.
The findings include:
The facility policy states: "An individualized treatment and rehabilitation plan will be developed with each client after the completion of the client's psycho-social evaluation. Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission."
On May 10 - 11, 2012, nine client records requiring documentation of an individual treatment and rehabilitation plan were reviewed.
The facility failed to document an individual and rehabilitation treatment plan per policy in three of nine records reviewed, specifically client records # 3, 6, and 9.
Client # 3 was admitted to the program on 2/28/12.
The individual treatment plan was to be documented within 3 days of admission, 3/2/12.
There was no documented individual treatment plan at the time of review on 5/11/12.
Client # 6 was admitted to the program on 12/13/11.
The individual treatment plan was to be documented within 3 days of admission, 12/16/11.
There was no documented individual treatment plan at the time of review on 5/11/12.
Client # 9 was admitted to the program on 6/8/11 and discharged on 1/26/12.
The individual treatment plan was to be documented within 3 days of admission, 6/15/11.
There was no documented individual treatment plan at the time of review on 5/11/12.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Program Supervisor will conduct an inservice with all clinical staff to review the policy which requires individualized treatment and rehabilitation plans and the timeframe for completion of such.
2. The Program Supervisor will ensure each clinican signs off on a copy of the policy for completion of individualized and rehabilitation plans and will submit to the Adminstrative Coordinator for filing in the personnel chart of each clinician.
3.The Program Supervisor and/or Program Director will review all individualized treatment and rehabilitation plans for timeliness and sign off as required for filing in the clinical chart of the respective client.
4. The Program Director will audit a random sample of individualized reahbilitation treatment plans for effectivenss, timeliness and completness for the required monthly CQI report. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records and a review of the project's policy and procedures manual, the facility failed to document a treatment and rehabilitation plan update per policy in two of eight records reviewed.
The findings include:
The project's policy states: "The individualized treatment plan shall be updated every 30 days."
On May 10 - 11, 2012, eight client records requiring documentation of a treatment and rehabilitation update were reviewed.
The facility failed to document a treatment plan update per policy in two of eight records reviewed, # 5 and 7.
Client # 5 was admitted to the program on 12/8/11.
The individual treatment plan in client # 5's record was dated 12/12/11.
A treatment plan update was due by 1/12/12, 2/12/12, 3/12/12, and 4/12/12, but at the time of inspection, the record did not contain one.
Client # 7 was admitted to the program on 1/6/12.
The individual treatment plan in client # 7's record was dated 2/13/12.
A treatment plan update was due by 3/13/12 and 4/13/12.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Program Supervisor will facilitate an inservice for all clinical staff focusing on the policy for the completion of individualized treatment plan updates and the required timeframe for completion.
2. The Program Supervisor will have each clinical staff sign off on the policy for individualized treatment plan updates and submit to the Administrative Coordinator for filing in the personnel chart of each clinical staff.
3. The Program Supervisor and/or Program Director will review each individualized treatment plan update on a monthly basis to ensure timeliness and sign off on each reviewed plan as required.
3. The Program Supervisor and/or Program Director will audit a random sample of individualized treatment plans to ensure compliance as stated in policy for the monthly required CQI report. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and an interview with the Facility Director, the facility failed to document individual counseling services in six of seven records reviewed.
The findings include:
On May 10 - 11, 2012, seven client records requiring documentation of individual counseling services were reviewed. The facility did not document individual counseling services in six of seven records reviewed, client records # 2, 3, 4, 5, 6, and 7.
Client # 2 was admitted to the program on 11/30/11.
The individual treatment plan in client # 2's record dated 12/31/11 prescribed individual sessions once a week. Client # 2's record did not document individual counseling sessions.
Client # 3 was admitted to the program on 2/28/12.
The facility did not document a treatment plan in client # 3's record; however, the Facility Director stated that individual sessions are to occur once a week. Client # 3's record did not document individual counseling sessions.
Client # 4 was admitted to the program on 8/8/11.
The individual treatment plan in client # 4's record dated 8/11/11 prescribed individual sessions once a week. Client # 4's record did not document individual counseling sessions.
Client # 5 was admitted to the program on 12/8/11.
The individual treatment plan in client # 5's record dated 12/12/12 prescribed individual sessions once a week. Client # 5's record did not document individual counseling sessions.
Client # 6 was admitted to the program on 12/13/11.
The facility did not document a treatment plan in client # 6's record; however, the Facility Director stated that individual sessions are to occur once a week. Client # 6's record did not document individual counseling sessions.
Client # 7 was admitted to the program on 1/6/12.
The individual treatment plan in client # 7's record dated 1/13/12 prescribed individual sessions once a week. Client # 7's record did not document individual counseling sessions.
The Program Supervisor confirmed the findings.
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Plan of Correction
1. The Program Supervisor will have all clinical staff submit a schedule of individual counseling sessions for their required caseload on a monthly basis.
2. The Program Supervisor will have all clinical staff submit individual counseling logs every Friday of each week for their assigned cseload and sign off on each as required.
3. The Program Director will audit a random sample of clinical charts and review the completeness of individual counseling sessions in each chart according to the number of weeks in the month.
4. The Program Supervisor will ensure that Individual Counseling session logs will be filed in the clinical charts weekly as required. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records and a review of the project's policy and procedures manual, the facility failed to document a record of services provided in nine of nine records reviewed.
The findings include:
The project's policy states: "Record of Services: All services rendered to a client shall be documented on the Record of Services form, which is maintained in the client record. The form should initially be completed with the intake paperwork. The Counselor or staff person scheduled to provide a service shall record the date a service is scheduled to be provided, the specific service and the initials of the staff responsible for the service. Documentation of this should be made promptly after the appointment is scheduled. The client's attendance status and the duration of the service shall be noted as soon as the disposition is known. A ROS is completed daily."
On May 10 - 11, 2012, nine client records requiring documentation of record of services provided were reviewed.
The facility failed to document a record of services provided in nine of nine records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, and 9.
Client # 1 was admitted to the program on 10/7/11.
Client # 1's record did not contain a record of service at the time of review on 5/11/12.
Client # 2 was admitted to the program on 11/30/11.
Client # 2's record did not contain a record of service at the time of review on 5/11/12.
Client # 3 was admitted to the program on 2/28/12.
Client # 3's record did not contain a record of service at the time of review on 5/11/12.
Client # 4 was admitted to the program on 8/8/11.
Client # 4's record did not contain a record of service at the time of review on 5/11/12.
Client # 5 was admitted to the program on 12/8/11.
Client # 5's record did not contain a record of service at the time of review on 5/11/12.
Client # 6 was admitted to the program on 12/13/11.
Client # 6's record did not contain a record of service at the time of review on 5/11/12.
Client # 7 was admitted to the program on 1/6/12.
Client # 7's record did not contain a record of service at the time of review on 5/11/12.
Client # 8 was admitted to the program on 10/7/11 and discharged on 1/10/12.
Client # 8's record did not contain a record of service at the time of review on 5/11/12.
Client # 9 was admitted to the program on 6/8/11 and discharged on 1/26/12.
Client # 9's record did not contain a record of service at the time of review on 5/11/12.
The Program Supervisor confirmed the findings.
This is a repeat citation. The facility was previously cited on 5/13/11.
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Plan of Correction
1. The Program Supervisor will conduct an inservice of the "policy" that outlines the documentation process for the Record of Service.
2. The Program Supervisor will ensure that entires are made on a weekly basis by conducting weekly audits of the Record of Service for each clinical chart.
3. The Program Director will monitor adherance to the policy for Record of Services by conducting a random clinical chart audit for CQI reporting as required on a monthly basis. |