INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on May 18, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Drc Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor as per the regulation.
The findings include:
The personnel record of employee #6, the facility's only clinical supervisor, was reviewed on May 15, 2015.
Employee # 6 was hired at the project on November 3, 2014. There was no documentation of supervision meetings for November 2014, January 2015 and March 2015.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The Outpatient Clinical Supervisor was hired on 5/12/14. Documentation of her completion of Orientation (9/12/14) and monthly supervisions (May-Dec 2014) were completed by Outpatient Program Director and given to Human Resources Department for placement in her personnel chart. The Outpatient Clinical Supervisor will have documented monthly supervisions with the Program Director the first six months in the position.
The Program Director will ensure the supervisions are filed in the personnel file kept by the Human Resources Department monthly.
The Outpatient Clinical Supervisor was hired on 5/12/14. Documentation of her completion of Orientation (9/12/14) and monthly supervisions (May-Dec 2014) were completed by Outpatient Program Director and given to Human Resources Department for placement in her personnel chart.
On 07/24/15 The Program Director reviewed the personnel chart of the Outpatient Clinical Supervisor to ensure that all supervisions have been filed.
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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, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of three personnel records reviewed.
The findings included:
Five personnel records were reviewed on May 18, 2015. The facility failed to document 25 clock hours of annual training in personnel record #4.
Employee # 4 was hired on September 26, 2006. The training year reviewed was January 1 through December 31, 2014. Employee # 4 only completed 22 clock hours of annual training in 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia DRC Inc. has an Annual Training calendar. The training calendar is effective January 1st through December 31st. The Clinical Supervisor will review the training hours of each counselor quarterly. The goal is for each counselor to have 8 hours of training each of the first three quarters.
The Clinical Supervisor will do a quarterly supervision with counselors regarding their training hours and schedule trainings as needed for the upcoming quarter. The 4th quarter trainings scheduled will to ensure training hours (25) compliance.
Outpatient Director will review the training hours with Clinical Supervisor each quarter.
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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, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of two new personnel records reviewed.
The findings include:
Five personnel records were reviewed on May 18, 2015. Employee #2 was hired March 26, 2015. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record #2.
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Plan of Correction
Instruction on the use of the fire extinguisher is a component of the new hire orientation.
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
This is accomplished via on-line participation in a fire extinguisher education and awareness program designed by industry professionals. It familiarizes employees with the general principles of fire extinguisher use and the hazards involved with incipient stage fire-fighting. Temporary hires will have this training documented as evidenced by a Certificate of Completion monitored and verified by the Program Director. The completion certificate will be kept in their personnel files.
Employee #2 completed the fire extinguisher training on 7/23/15 via on-line course at www.firexetinguisher.com
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the facility's fire drill record, the facility failed to document alternate exits during fire drills and failed to document whether or not the alarm system was set off during fire drills. Additionally, the facility failed to document whether or not one of two new employees obtained the required training when it comes to emergencies.
The findings include:
The fire drill record was reviewed on May 18, 2015 from December 2014 to April 2015. On the following dates the facility documented N stating that the alarm was not set off; 3/18/15 and 4/28/15. On the following days the facility documented Y&N, but did not document if the facility actually set off the alarm; 12/19/14, 1/8/15 and 2/6/15. Additionally, the facility failed to ensure that employee #2, who was hired on March 26, 2015, was trained for emergencies upon being hired.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that alternate (rotating) exits are used during Fire Drills and evacuations and these exercises are documented according to licensing standards.
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
The Program Director will identify the exit to be used prior to the monthly fire drill and will direct participants to the designated exits.
The Program Director will document whether or not the alarm system was set off during fire drills.
Instructions on fire drills and evacuations are components of the new hire orientation. New hires will have their orientation documented and kept in their personnel files.
Employee #2 completed the fire emergency/disaster plan procedures training on 7/23/15. The training was facilitated by the Program Director.
Documentation of fire drills is done by the Program Director. In absence of the Program Director, the Clinical Supervisor was trained in how to properly document alternate exits when conducting a fire drill. The training was facilitated by the Program Director.
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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, the facility failed to obtain informed and voluntary consents in one of eleven records reviewed.
The findings include:
Eleven client records were reviewed on May 18, 2015. The facility failed to document informed and voluntary consents in client record, #11.
Client #11 - Consent to release dated November 5, 2014 for the client's emergency contact failed to have the client's signature on the consent to release form. The client record reviewed confirmed that information was released to those entities in reliance of the release forms that wasn't signed by the client. Additionally, consent to releases date November 5, 2014 for the client's parole officer and a government agency failed to have the date the client signed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the licensing inspection dated 10/16/14.
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Plan of Correction
The Intake Supervisor will review all intake documentation daily to ensure that all of the signatures and dates have been obtained.
The Clinical Supervisor will review the intake section of the clinical chart when doing monthly open chart audits and will have the client review, confirm, date and sign consent forms as needed.
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
The Intake Supervisor reviewed client #11 chart and removed the unsigned emergency contact because there were multiple emergency contacts. The date the client signed the consent to release for his parole officer and government agency was entered by Intake Supervisor because she had facilitated the intake client #11.
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to show that they offered the client a copy of their consent to release form in one of eleven client records reviewed.
The findings include:
Seven client records were reviewed on May 18, 2015. The facility failed to document in client #6's record that the client was offered a copy of their consent dated January 22, 2015 to the client's insurance company.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the licensing inspection dated 10/16/14.
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Plan of Correction
The Intake Supervisor will review intake documentation daily to ensure that there is evidence the client was a offered copies of their consent to release forms. If it is not indicated the client will be contacted and offered copies of their consent forms as needed.
The Clinical Supervisor will review intake documentation during monthly open chart audits to ensure that there is evidence the client was a offered copies of their consent to release forms. If it is not indicated the client will be contacted and offered copies of their consent forms as needed.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. 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 client history in four of eleven client records reviewed.
The findings include:
Eleven client records were reviewed for the documentation of a history on May 18, 2015. The facility failed to provide documentation of a client's history in client records,2, 5, 6 and 11.
Client # 2 was admitted on November 20, 2014 and discharged on December 18, 2014. As of the date of the licensing inspection the facility failed to document client #2's medical, personal history and drug/alcohol history.
Client # 5 was admitted on April 13, 2015. As of the date of the licensing inspection the facility failed to document client #5's personal and drug/alcohol history.
Client # 6 was admitted on January 22, 2015. As of the date of the licensing inspection the facility failed to document client #6's medical, personal and drug/alcohol history.
Client # 11 was admitted on November 5, 2014 and discharged on February 18, 2015. As of the date of the licensing inspection the facility failed to document client #11's medical, personal and drug/alcohol history.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Addiction Severity Index (ASI) is completed during the intake process. The ASI is used for the assessment of substance use-related problems. The ASI will get a better understanding of the participant?s treatment needs and outcomes. Instead of just considering the participant?s substance use, the ASI as aims it?s spotlight on the individual?s medical, employment, legal, family, social and psychiatric status. This wide angle view is designed to assist in getting a better understanding not just of the substance use, it also other problems that affect the participant and his/her recovery.
Client #2 ASI was completed during Intake on 11/20/14.
Client #5 ASI was completed during Intake on 04/13/15.
Client #6 ASI was completed during Intake on 01/22/15.
Client #11 ASI was completed during Intake on 11/05/14.
The Intake Supervisor will review intake documentation daily to ensure that the ASI has been completed.
The Clinical Supervisor will review intake documentation to ensure that the ASI has been completed when doing monthly open chart audits.
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
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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
Based on a review of client records, the facility failed to document a psychosocial evaluation in seven of eleven client records.
The findings include:
Eleven client records were reviewed on May 18, 2015 for documentation of a psychosocial evaluation. The facility failed to provide documentation of a psychosocial evaluation in client records # 2, 3, 5, 6, 7, 8 and 11.
Client # 2 was admitted on November 20, 2014 and discharged on December 18, 2014. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 3 was admitted on September 29, 2014 and discharged on March 3, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 5 was admitted on April 13, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 6 was admitted on January 22, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 7 was admitted on February 24, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 8 was admitted on February 26, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
Client # 11 was admitted on November 5, 2015 and discharged on February 18, 2015. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client will meet with Primary Counselor for individual counseling sessions once weekly. The primary counselor will focus on establishing rapport with the client while discussing the D&A and Med/Psych histories and the data collected during the intake. The counselor will begin gathering data to complete the Psychosocial History. The counselor is expected to fully complete the family history, legal history, employment/vocational history, educational history, sexual history, abuse history, recreational/leisure time history, military history and treatment receptivity within three individual sessions. Upon completion of the Psychosocial History the counselor will write a psychosocial assessment and submit to Clinical Supervisor for review prior to the next individual session.
The Program Director will monitor due dates for psychosocial weekly. Pending psychosocial will be reviewed at weekly clinical staff meetings.
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
The Program Director reviewed Client #2 chart and the psychosocial was started but not completed due to client rotating to a program closer to his home on prior to 30 days on 12/18/14.
The Program Director reviewed Client #3 chart and bio-psychosocial was completed on 10/30/14.
The Program Director reviewed Client #5 chart and the psychosocial was started but not completed due to client hospitalization and program discharge on 5/18/15.
The Program Director reviewed Client #6 chart and bio-psychosocial was completed on 2/16/15.
The Program Director reviewed Client #7 chart and bio-psychosocial was completed on 3/24/15.
The Program Director reviewed Client #8 chart and bio-psychosocial was completed on 3/26/15.
The Program Director reviewed Client #11 chart and bio-psychosocial was completed on 12/04/14.
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709.92(a) 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:
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Observations
Based on review of client records, the facility failed to document an individual treatment and rehabilitation plan in two of ten client records reviewed.
The findings include:
Ten client records were reviewed on May 18, 2015 for documentation of an individual treatment and rehabilitation plan. The facility failed to document individual treatment and rehabilitation plans in records, #5 and 8. Additionally, the facility failed to include on the individual treatment and plan the type & frequency in one of three client record, #6.
Client #5 was admitted on April 13, 2015. Client #5's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
Client #6 was admitted on January 22, 2015. Client #6's individual treatment and rehabilitation plan developed on February 16, 2015 did not include type and frequency of sessions.
Client #8 was admitted on February 26, 2015. Client #8's individual treatment and rehabilitation plan was not documented as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the psychosocial assessment, the primary counselor shall formulate an individualized treatment plan citing a diagnosis, specific problems, goals, action steps to achieve the goals and target dates. The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor, Medical Director (or psychiatrist) and client by the fourth counseling appointment and updates completed every 30 (1B) or 60 (1A) days thereafter.
The Program Director will monitor due dates for Treatment plans and Treatment plan updates weekly. Pending Treatment plans and updates will be reviewed during weekly clinical staff meetings.
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
The Program Director reviewed Client #5 chart and the individual treatment and rehabilitation plan was not completed due to client hospitalization and program discharge on 5/18/15.
The Program Director reviewed Client #6 chart and individual treatment and rehabilitation plans were completed on 2/16/15 and 4/24/15.
The Program Director reviewed Client #8 chart and the correct admit date is 03/09/15. The individual treatment and rehabilitation plan was completed on 4/08/15.
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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 plan update per regulations in two of six client records reviewed.
The findings include:
Six client records requiring treatment plant updates were reviewed on May 18, 2015. The facility failed to document the client's treatment plan update within 30 days of the client comprehensive treatment plan in two client records, #6 and 10.
Client #6 was admitted on January 22, 2015. The comprehensive treatment plan was completed on February 16, 2015. A treatment plan update was due by April 16, 2015 and was not completed until April 24, 2015.
Client #10 was admitted on January 27, 2015. The comprehensive treatment plan was completed on February 25, 2015. A treatment plan update was due by April 25, 2015 and was not completed until April 29, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the psychosocial assessment, the primary counselor shall formulate an individualized treatment plan citing a diagnosis, specific problems, goals, action steps to achieve the goals and target dates. The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor, Medical Director (or psychiatrist) and client by the fourth counseling appointment and updates completed every 30 (1B) or 60 (1A) days thereafter.
The Program Director will monitor due dates for Treatment plans and Treatment plan updates weekly. Pending Treatment plans and updates will be reviewed during weekly clinical staff meetings
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
The Clinical Supervisor will do supervision with the assigned counselor for Client #6 and Client #10 regarding compliance with timeframe for treatment plan updates.
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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 client records, the facility failed to maintain a complete record in five of eleven records reviewed.
The findings include:
Eleven client records were reviewed on March 18, 2015. The facility failed to maintain a complete record for clients, #6, 7, 8, 9, 10 and 11.
Client #6 was admitted on January 15, 2015 and was still an active client. The facility documented on the client's record of service, services rendered but failed to provide progress notes to review; 1/26/15, 1/27/15, 1/29/15, 2/12/15, 2/16/15, 2/17/15, 2/19/15, 2/23/15, 2/26/15, 3/2/15, 3/3/15, 3/12/15, 3/27/15, 4/6/15, 4/7/15, 4/9/15, 4/14/15, 4/16/15, 4/21/15, 4/24/15, 5/1/15 and 5/8/15. Additionally, the following progress notes were reviewed, but the facility failed to document them on the client's record of service; 2/2/15, 3/17/15 and 3/31/15.
Client #7 was admitted on February 25, 2015 and was still an active client. The facility documented on the client's record of service, services rendered but failed to provide progress notes to review; 3/3/15, 3/12/15, 3/26/15, 4/3/15, 4/7/15, 4/9/15, 4/14/15, 4/16/15, 4/21/15, 4/23/15, 4/28/15, 4/30/15, 5/5/15, 5/7/15, 5/14/15 and 5/15/15.
Client #8 was admitted on February 26, 2015 and was still an active client. The facility documented on the client's record of service, services rendered but failed to provide progress notes to review; 3/9/15, 3/10/15, 3/11/15, 3/17/15, 3/18/15, 3/19/15, 3/31/15, 4/1/15, 4/7/15, 4/8/15, 4/14/15, 4/23/15 and 4/29/15. Additionally, the following progress notes were reviewed, but the facility failed to document them on the client's record of service; 2/27/15, 4/28/15, 5/5/15, 5/11/15, 5/12/15 and 5/14/15.
Client #9 was admitted on October 30, 2014 and was still an active client. The facility documented on the client's record of service, services rendered but failed to provide progress notes to review; 10/30/14, 11/4/14, 11/11/14, 11/18/14, 12/2/14, 12/9/14, 12/17/14, 12/23/14, 12/24/14, 12/26/14, 12/30/14, 12/31/14, 1/23/15, 1/27/15, 2/6/15, 3/3/15, 3/11/15, 3/18/15, 3/25/15, 4/3/15, 4/7/15, 4//28/15 and 5/8/15.
Client #10 was admitted on January 27, 2015 and was still an active client. The facility documented on the client's record of service, services rendered but failed to provide progress notes to review; 4/14/15, 4/16/15, 4/21/15, 4/22/15, 4/28/15, 4/29/15, 5/5/15, 5/7/15 and 5/12/15.
Client #11 was admitted on November 5, 2014 and discharged on February 18, 2015. The facility documented on the client's record of service, services rendered but failed to provide progress notes to review; 12/5/14, 12/17/14, 12/19/14, 12/22/14, 12/26/14, 1/6/15, 1/7/15, and 1/19/15. Additionally, the following progress notes were reviewed, but the facility failed to document them on the client's record of service; 11/5/14, 12/31/14, 1/26/15, 2/2/15 and 2/3/15. The facility also failed to document client #11's case consultation as of the date of the client's discharge date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the psychosocial assessment, the primary counselor shall formulate an individualized treatment plan citing a diagnosis, specific problems, goals, action steps to achieve the goals and target dates. The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor, Medical Director (or psychiatrist) and client by the fourth counseling appointment and updates completed every 30 (1B) or 60 (1A) days thereafter.
The Program Director will monitor due dates for Treatment plans and Treatment plan updates weekly. Pending Treatment plans and updates will be reviewed during weekly clinical staff meetings
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
The Clinical Supervisor will do supervision with the assigned counselor for Client #6 and Client #10 regarding compliance with timeframe for treatment plan updates.
All services rendered to a client shall be documented on the Outpatient Service Record Form, which is maintained in the client record. The Counselor or staff person providing the service shall record the date a service is provided and complete the group or individual note.
The Clinical Supervisor will review the Outpatient Service Record and supporting documentation when doing monthly open chart audits to ensure documentation is being completed and filed in the client record.
Case consults are performed every 90 days and 60 days thereafter. Case consults will be performed more frequently whenever a client has a special issue of concern requiring team consultation.
The Program Director will monitor due dates for Case consults and Case consult updates weekly. Pending Case consults and updates will be reviewed at weekly clinical staff meetings.
This Plan of Correction was reviewed and discussed during the Outpatient staff meeting by the Program Director on 07/07/15.
The Clinical Supervisor will review the clinical charts of Client #6, Client #7, Client #8, Client #9, Client #10 and Client #11 to ensure that all group and individual progress notes are present.
The Clinical Supervisor will utilize Outpatient Service Record to identify the clinician responsible for documenting the clinical session.
The Program Director filed 01/21/15 Case Consultation note for Client #11 on 07/07/15.
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