INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia, Inc. Outreach 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that employee #6 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe. Employee #6 was hired as counselor on 4/14/16 and was due to have HIV/AIDS training no later than 4/14/17. There was no documentation of the completion of the HIV/AIDS training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #6 will be addressed during personal supervision by program supervisor. Employee #6 has been added to the training list for 8/15/17 for the HIV/AIDS training.Program Supervisor will review required training's during weekly staff Meetings to ensure staff compliance . Division director will follow up to ensure compliance by 8/16/17. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on 6/15/2017 at 1:30 PM., it was observed that the facility failed to ensure privacy of counseling sessions as the door to group room # 2 and the door to counselor room 118 were left wide open while a group session and an individual session were occuring respectively; thus allowing both sessions to be heard and seen from the hallway.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisor will meet with clinical staff during a team meeting on 6/23/17 at 4pm to discuss the confidentiality requirement that all group room doors and individual counselor doors will be closed during group and individual sessions. Division director will follow up to ensure compliance by 5pm 6/23/17. |
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.
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Observations
Based on a review of 15 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 2 client records. Additionally, 2 client records had consent to release information forms that were missing required components.
Client #4 was admitted on 4/6/16 and was discharged 2/24/17. There was a consent to release form signed and dated on 4/18/16 to an outside agency, which did not include a witness signature.
Client #7 was admitted on 12/1/16 and was discharged 4/24/17. There were two consent to release forms signed and dated on 12/1/16, that did not include the name of the person, agency, or organization to whom the disclosure was to be made to, the specific information to be disclosed, and purpose of the disclosure. Additionally, the record contained documentation that the facility communicated with an outside agency for which there was no consent to release form prior to disclosure.
Client #10 was assessed for the Intake, Evaluation and Referral level of care on 5/8/17. There was documentation that the facility had billed the funding source; however, there was no consent to release information form on file prior to the disclosure.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Clinical staff will be addressed by Program supervisor during team meeting on 6/23/17 on the requirement that the informed and voluntary consent to release information form must be completed prior to the disclosure of information. Also, a consent to relapse information must be present in the chart and signed by all parties before information can be disseminated. Also, all consents must be completed in their entirety before any personal information can be released. This process will be overseen and compliance will be ensured by the Division director by 6/23/17. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of 15 client records, each client record reviewed lacked documentation verifying written acknowledgement by clients that they had been notified of each of the client rights, including that facility staff may limit access to their records if determined to be detrimental, the right to appeal a decision limiting access to their records, and the right to request the correction of inaccurate information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisor will address the staff in their team meeting on 6/30/17 in reference to the need for all clients to be notified of their rights including that facility staff may limit access to their records if determined to be detrimental, the right to appeal a decision limiting access to their records, and the right to request the correction of inaccurate information in the record. All clients will be given the Gaudenzia Client Rights to sign and the signed copy will then be placed in each individuals client file at their next individual session. This process will be overseen and compliance will be ensured by the Division Director by 6/30/17.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of nine client records, the facility failed to document that services were provided consistent with the type and frequency specified in the individual treatment and rehabilitation plans in client record #'s 1, 2, and 7.
Client #1 was admitted on 1/20/17 and was an active client at time of inspection. The individual treatment and rehabilitation plans completed on 3/1/17 and 3/31/17 specified that the client participate in individual therapy 1 time per week. However, the record of service, the lack of progress notes, and the lack of documented no-shows/cancellations from 3/1/17 through 4/14/17 reflected that the client did not attend any individual sessions.
Client #2 was admitted on 1/3/17 and was an active client at time of inspection. The individual treatment and rehabilitation plan completed on 4/13/17 specified that the client participate in group therapy 2 times per week. However, the record contained only one group note from 4/27/17 through 6/5/17, with no documented no-shows/cancellations during that timeframe.
Client #7 was admitted on 12/1/16 and was still an active client at the time of inspection. The individual treatment and rehabilitation plan completed on 1/26/17 specified that the client participate in individual therapy 1 time per week. However, the record of service, the lack of progress notes, and the lack of documented no-shows/cancellations from 1/26/17 through 3/31/17 reflected that the client did not attend any individual sessions.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisor will address the lack of individual and group sessions per individual receiving services, additionally, she will ensure that the treatment plans reflect the actual number of individual and group sessions the client is actually engaged in on 6/30/17. Program supervisor will ensure that no show/cancellation notes will appear in the charts reflecting lack of attendance.
All individual and group progress notes including no-shows and cancellations will be submitted to the program supervisor on a weekly basis. The program supervisor will then be responsible to track the notes to ensure all are submitted. If a counselor does not submit all notes as required for the week a supervision will be conducted with the staff member.
Division Director will ensure compliance of this process by 07/14/2017 |
709.93(a) 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:
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Observations
Based on a review of 9 client records, the facility failed to provide a complete client record in client records #'s 3, 4, 5, 7, and 9.
Client #3 was admitted on 3/30/16 and was discharged on 11/17/16. The client record contained an incomplete record of services, which was not updated since 4/11/16, despite progress notes for therapy in July, August, September, October, and November.
Client #4 was admitted on 04/6/2016 and was discharged on 2/24/17. The client record did not contain any documentation of follow-up information as of the date of the inspection.
Client #5 was admitted on 4/24/17 and was an active client at the time of inspection. The client record did not contain any documentation of record of services as of the date of the inspection.
Client #7 was admitted on 12/16/16 and was an active client at the time of inspection. The client record did not contain any documentation of record of services as of the date of the inspection.
Client #9 was admitted on 03/10/16 and was discharged on 10/7/16. The client record did not contain any documentation of follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program supervisor will meet with administrative staff in staff Meeting 6/30/17 to discuss the lack of records of service in Chart #3-it stopped on 4.16.16 and needs to be updated to include July August September and October and November.Chart #4-was admitted 4.6.16 and was discharged on 2.24.27-it needs follow up information.Chart #5-client was admitted 4.24.17 this chart needs a record of service none was in there at time of inspection.Chart #7-was admitted on 12.16.17 there is no record of service it needs one. Chart #9-admitted on 3.10.16 and discharged 10.7.16-There was no follow up information and there needs to be follow up information . The Administrative staff will correct these deficiencies by the 14th of July. The administrative staff and Program Supervisor will meet on a monthly basis to ensure compliance to this corrective action. Division Director will ensure compliance of this process by 7.14.17. |