INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on February 7 and 8, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on March 13, 2007.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The assessment of staff training needs lacked signatures and dates to verify when they were completed.
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Plan of Correction
The yearly Staff Training Needs Assessment Forms will be revised to include signatures and dates to verify when they were completed. Program Directors will be responsible for securing these signatures and dates during yearly training evaluation needs sessions.
Persons Responsible:
Division Director and Outpatient Program Director
Timeframe for Completion: February 26, 2007
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Feedback forms were not completed for all training attended.
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Plan of Correction
After every training attended by the Outpatient Staff, feedback forms will be distributed by the Human Resource Department. These forms will be completed and given to the Human Resource Staff person responsible for the training. Certificates will not be given to the trainee until these forms are filled out. The Outpatient Program Director will be given copies of the trainings attended and the accompanying feedback forms to monitor this process.
Persons Responsible:
Outpatient Program Director and Human Resource Manager
Timeframe for Completion: April 15, 2007 and ongoing.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Alternate route were not being utilized and documented during fire drills.
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Plan of Correction
Effective February 22, 2007 Alternate routes will be utilized and documented during fire drills.
The Program Director will monitor the fire drills monthly to ensure continued compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible: Outpatient Program Director
Timeframe for Completion: April 1, 2007
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Physical examinations were not completed within the facility's identified time frame in four of five client records reviewed, #2, 3, 7 and 10.
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Plan of Correction
The Standard for Outpatient Activities 709.91 (b)(5) states, "Physical Examination, if applicable". The Gaudenzia DRC, Inc. Outpatient Manual will be changed to reflect standard 709.91(b)(5) and Outpatient Program clients will be scheduled for physical examinations as needed.
Persons Responsible:
Division Director and Outpatient Program Director
Timeframe for Completion: March 9, 2007
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation was missing in client record #1. Psychosocial evaluations did not address client problems and needs in three of eight client records reviewed, #2, 3, and 10. Client assets and strengths were not documented in three of eight client records reviewed, #2, 3 and 7. Coping mechanisms were missing in four of eight client records reviewed, #3, 4, 7 and 8. The client's support systems were not addressed in four of eight client records reviewed, #2, 3, 7 and 10.
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Plan of Correction
On March 12, 2007 training will be provided to the Outpatient Counselors on "Psychosocial Evaluations". By March 31, 2007 the Program Director and clinical supervisor will review each active chart to ensure that there is a composite picture to include addressing client problems, strengths and weaknesses, coping mechanisms, and identifying client support systems of the individual client in the evaluation. The Program Director will monitor clients' charts to ensure continued compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: May 1, 2007
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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
Goals did not include measurable action steps in four of nine records reviewed, #3, 5, 8 and 10. Action steps were missing in two of nine records reviewed, #1 and 7.
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Plan of Correction
On March 19, 2007 training will be provided to the Outpatient Counselors on "Treatment Planning". By March 31, 2007 the Program Director and Clinical Supervisor will have reviewed each chart to ensure that treatment plan goals consistently include measurable action steps. The Program Director will monitor clients' charts to ensure continued compliance via the Monthly Continuous Quality Improvement (CQI) process.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: May 19, 2007
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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
Treatment plan updates did not include a review of progress on previously stated goals in five of seven records reviewed, #2, 3, 6, 8 and 10.
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Plan of Correction
On March 19, 2007 an agenda will be completed and training provided to the Outpatient Counselors on "Treatment Planning". By March 31, 2007 the program director and clinical supervisor will review every chart to ensure that treatment plan updates include a review of progress made on previously stated goals. The Program Director will continue to monitor clients' charts to ensure compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: May 19, 2007
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Case consultations were missing in four of ten client records reviewed, #1, 4, 7 and 8.
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Plan of Correction
On March 26, 2007 training will be provided to the outpatient counselors on "Documentation of Case Consultations". By March 31, 2007 the program director and clinical supervisor will review every chart to ensure that Case Consultations are completed every 90 days per DOH Standards for Outpatient Activities. The program director will monitor clients' charts to ensure continued compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible:
Outpatient Program Director and Outpatient Clinical Supervisor
Timeframe for Completion: May 19, 2007
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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
The follow-up policy for clients who are not referred does not indicate a time frame when the follow up will be completed, who is responsible for the contact or how it will be documented.
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Plan of Correction
On February 26, 2007 the Gaudenzia DRC, Inc. Manual will include a follow up policy for clients who are not referred that will indicate a time frame when the follow up will be completed, who is responsible for the contact, or how it will be documented. By March 31, 2007 the Program Director and clinical supervisor will review every closed chart to ensure that client follow up policy occurs within 30 days of discharge from the Outpatient Program. The Program Director will monitor clients' closed charts to ensure continued compliance via the monthly Continuous Quality Improvement (CQI) process.
Persons Responsible:
Division Director and Outpatient Program Director
Timeframe for Completion: May 19, 2007
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