INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 2011 through June 2, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Washington House 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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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on an interview with the facility director, the facility failed to provide a written agreement with a licensed hospital or physician for 24-hour medical coverage.
The findings include:
From June 1, 2011 to June 2, 2011, the Licensing Specialist asked to see a copy of the facility's written agreement with a licensed hospital or physician for 24-hour emergency medical coverage. A written agreement with a licensed hospital or physician for 24-hour emergency medical coverage was not presented for review.
An interview with the facility director conducted on June 2, 2011 at approximately 1:00 P.M. confirmed that the facility did not have a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
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Plan of Correction
Washington House has renewed its Service Linkage agreement with PA Hospital/Hall Mercer. The Adminisrative Coordinator had the letter of agreement renewed on 6/22/11. Ninety days before the referral agreement is to expire the Administrative Coordinator will contact the hospital CRC manager to renew the letter of agreement. The Program Director will remind the Administrator Coordinator to renew the Service Linkage agreement 90 days prior to expiration to ensure that there is always 24 hour emergency medical coverage for clients at Washington House. |
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 an interview with the facility director, the facility failed to ensure that a client's consent to release information must be in writing in three of four records reviewed.
Also, based on a review of client records and an interview with the facility director, the facility failed to ensure that the client is notified of his/her right to revoke client consent to release information verbally or in writing in three of four records reviewed.
The findings include:
From June 1, 2011 to June 2, 2011, four records were reviewed for consent to release information. The facility's consent to release form had verbiage that permitted the facility to act in reliance on a client's verbal consent to release information in client records # 2, 3, and 4. Also, the same consent to release form had verbiage that only gave the client the right to revoke in writing in client records # 2, 3, and 4. "I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written or verbal consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time in writing to the Program Director of Washington House, except to the extent that action has been taken in reliance on it (e.g., probation, parole, etc.) and that in any event this consent automatically as describe below."
Client record # 2
1. Two consents to release for Community Behavioral Health dated 5/12/11
permitted the facility to act in reliance on a client's verbal consent. Also, the
consents did not give the client the right to revoke in writing or verbally.
Client record # 3
1. Two consents to release for Department Of Public Welfare dated 2/9/11 permitted the facility to act in reliance on a client's verbal consent. Also, the consents did not give the client the right to revoke in writing or verbally.
2. Two consents to release for Community Behavioral Health dated 2/9/11 permitted the facility to act in reliance on a client's verbal consent. Also, the consents did not give the client the right to revoke in writing or verbally.
Client record # 4
1.Two consents to release for Community Behavioral Health dated 3/29/11 permitted the facility to act in reliance on a client's verbal consent. Also, the consents did not give the client the right to revoke in writing or verbally.
2.Two consents to release for Department Of Public Welfare dated 3/29/11 permitted the facility to act in reliance on a client's verbal consent. Also, the consents did not give the client the right to revoke in writing or verbally.
During ongoing dialogues with the facility director conducted from approximately 10:30 A.M. to 3:45 P.M. on June 1, 2011 and conducted from approximately 8:30 A.M. to 1:00 P.M. on June 2, 2011, it was confirmed that the facility's consent to release form had verbiage that permitted the facility to act in reliance on a client's verbal consent to release information in client records # 2, 3, and 4. Also, during the same ongoing dialogues, it was confirmed that the same consent to release form had verbiage that only gave the client the right to revoke in writing in client records # 2, 3, and 4.
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Plan of Correction
Washington House is now using the revised Confidentiality Form that was issued from Gaudenzia's corporate office on June 8, 2011. The new revised Confidentiality Form now says information cannot be disclosed without a client's "written consent"; it also states that a client may revoke the consent at any time "verbally or in writing". All old Confidentiality Forms were destroyed on 6/8/11. Clients #2, 3 and 4 who were discharged 6/2/11, 6/3/11 and 6/8/11 did not receive the revised Confidentiality Form due to their discharge date being prior to our receipt of the revised Confidentiality Form. Going forward, the Intake Specialist will be responsible for getting signatures for all new admissions to the program. The Clinical Supervisor will monitor the chart within a 72 hour period to ensure signatures have been obtained on all Release of Information documents. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on review of the facility's policy and procedures, the facility's medication inspection records, and an interview with the facility director and the Licensed Practical Nurse, the facility failed to document inspection of medication storage areas.
The findings include:
The facility's policy titled: "Medication Control - Pharmacy Services," states:
"The nurse will make monthly inspections of all drug storage units to include emergency equipment and medical supplies. These areas are maintained in compliance with Federal, State and local regulations.
(a) A record of these inspections is maintained to verify that the following requirements are met.
(b) Distribution and administration of all drugs, including controlled substances is adequately documented.
(c) Outdated drugs are not stocked.
(d) Drugs requiring special conditions, for storage to assure stability are appropriately stored in a medicine cabinet or refrigerator.
(e) Disinfectants and drugs for external use are stored at the bottom of the medicine cabinet. Internal medications are stored on the top two shelves of the medicine cabinet.
(f) Controlled substances and other drugs of abuse are stored in accordance with Federal, State and Program regulations. Copies of drug regulations are available in appropriate areas."
Medication inspection records were reviewed on June 2, 2011. The records were reviewed from the period covering July 2010 to June 2011. In all those months the facility did not have documentation for an inspection of medication storage areas.
An interview with the facility director and the Licensed Practical Nurse conducted on June 2, 2011 at approximately 2:00 P.M. confirmed that the facility did not have documentation for an inspection of medication storage areas from July 2010 to June 2011. Also, during the same interview at approximately 2:00 P.M., the Licensed Practical Nurse stated the facility's last inspection of medication storage areas was conducted on April 30, 2010.
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Plan of Correction
The nurse at Washington House is now implementing documentation into the "Monthly Medical Log book,as well as the Disposal of Medcation log book. Documentation for both the Medcation and Disposal of Medcation log books began on 6/3/11. The nurse began doing monthly inspections of all drug storage units on 6/3/11. The program director will be responsible for meeting with the nurse monthly to review both log books listed above; the program director will ensure that this doesn't become a deficiency in the future by checking both log books listed above and meeting with the program nurse monthly. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review client records and an interview with the facility director, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in two of two records reviewed.
On June 2, 2011, two records were viewed for documentation of a written notice to the client for the reason to involuntarily terminate the client's treatment. The facility did not document a written notice to the client for the reason to involuntarily terminate the client's treatment in client records # 5 and 7.
The facility's policy title: "Policy & Procedure For Client Notification Of Termination & Client Right To Appeal Treatment Termination," states:
"Clients shall be advised in writing of the reasons for therapeutic discharge and may discuss reasons with counseling staff. Prior intervention efforts are required and shall be appropriately documented before a Therapeutic Discharge Notice may be given to a client. Exceptions to this policy include significant risk of harm to staff and others. A copy of the Therapeutic Discharge Notice will be maintained in the client record. Clients shall be informed of alternate treatment sources. Additional details are noted under standard 709.51.a., Plan for Intake and Admission, Involuntary Discharge/Termination Criteria. Clients shall be informed of their right to appeal any therapeutic discharge, in writing to the Program Director, within fifteen days of the notice. The right to appeal statement shall be noted on the Therapeutic Discharge Notice."
Client # 5 was admitted January 6, 2011 and was involuntarily terminated on February 28, 2011; however, client # 5's record did not include documentation of a written notice to the client for the reason to involuntarily terminate the client's treatment.
Client # 7 was admitted April 7, 2011 and was involuntarily terminated on May 17, 2011; however, client # 7's record did not include documentation of a written notice to the client for the reason to involuntarily terminate the client's treatment.
During an ongoing dialogue with the facility director conducted on June 2, 2011 from approximately 9:00 A.M. to 1:00 P.M., it was confirmed that the facility did not document a written notice to the client for the reason to involuntarily terminate the client's treatment in client records # 5 and 7.
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Plan of Correction
Washington House clinical staff now have "Termination Letter documents that they will use when treatment for any client is terminated. The Termination Letter was drafted on June 6,2011. The Clinical Supervisor will monitor each counselor. She will meet with the counselor prior to the discharge of any client whose treatment may be terminated, as well as ensure that the client has recieved the Termination letter.On July 19, 2011, Termination Letters were mailed to Clients #5 and 7. Copies of the letters have been placed in charts #5 and 7. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observation upon arriving at the facility on June 1, 2011 and an interview with the facility director, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
Upon arriving at the facility it was observed at approximately 7:45 A.M. that the facility had two dumpsters located in the facility's parking lot. One of the dumpsters was not covered with lids. However, the facility covered the dumpster with lids sometime before the end of the inspection on that day.
An interview with the facility director conducted on June 1, 2011 at approximately 9:30 A.M. confirmed that the one of the dumpsters was not covered with lids.
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Plan of Correction
One of the House Managers covered the dumpster with the lids on 6/1/11 during the inspection after the licensing specialist observed one of the dumpsters not being covered with lids. House Manager staff on all shifts at Washington House will do outdoor runs to ensure that the dumpster lids are closed at all times.
Program Director will make sure that House Manager staff keep dumpster lids closed at all times. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to ensure that hot food was served at or above 140 F.
The findings include:
A physical plant inspection was conducted on June 2, 2011. During the inspection, the Licensing Specialist asked to see a food serving temperature log. A food serving temperature log was not presented for review; therefore, it was no way to determine if hot food at the facility had been served at or above 140 F.
An interview with the facility director and Licensed Practical Nurse conducted on June 2, 2011 at approximately 2:35 P.M. confirmed that the facility does not have a food serving temperature log. Also, during the same interview, the facility director explained that residents at the facility frequently cook food for everyone at the facility but do not record the temperatures of the hot food served at the facility.
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Plan of Correction
All staff at Washington House will attend an in service training on Friday July 1,2011. Each staff person will be instructed on how to use a thermometer to ensure that cold food is to be refrigerated at or below 40F, frozen food kept at or below zero farenheit, hot food is kept at or above 140 F. In addition the temperture of each meal will be taken and recorded on a daily log sheet by House Manager staff.The Clinical Supervisor will review each days temperature log and on Monday mornings she will review weekend temperature log sheets to ensure that temperatures are recorded. |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on an interview with the facility director, the facility failed to provide written procedures for staff and residents to follow in case of an emergency for the evacuation and transfer of residents impaired by alcohol or other drugs.
The findings include:
From June 1, 2011 to June 2, 2011, the Licensing Specialist asked to see the facility's written procedures for staff and residents to follow in case of an emergency for the evacuation and transfer of residents impaired by alcohol or other drugs. Written procedures for staff and residents to follow in case of an emergency for the evacuation and transfer of residents impaired by alcohol or other drugs was not presented for review.
An interview with the facility director conducted on June 2, 2011 at approximately 12:30 P.M. confirmed that the facility does not have written procedures for staff and residents to follow in case of an emergency for the evacuation and transfer of residents impaired by alcohol or other drugs.
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Plan of Correction
The facility completed a written procedure for staff and residents to follow in case of an emergency for evacuation and transfer of residents impaired by alcohol or other drugs on July 1,2011. The program director completed the written procedure on July 1,2011. A copy of the emergency evacuation and transfer of residents impaired by alcohol and other drugs has been posted in each staff person's office to ensure that the procedure is conducted correctly. The program director will be responsible for monitoring this procedure. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a physical examination in accordance with the facility's policy and procedures in three of four client records reviewed.
Also, based on a review of client records and an interview with the facility director, the facility failed to document a physical examination in one of four client records reviewed.
The findings include:
From June 1, 2011 to June 2, 2011, four client records were reviewed for documentation of physical examinations. The facility did not document a physical examination in accordance with the facility's policy and procedures in client records # 1, 3, and 4. Also, the facility did not document a physical examination in client record # 2.
The facility's policy titled: "Physical Examination Laboratory Studies," states:
"A client entering a Gaudenzia (residential) program shall receive a complete physical examination by a qualified physician within 7 days of admission (DOH), except on holiday or weekend. Other exceptions are:
1. The client received a complete physical examination no longer than one month prior to
admission; that the program staff can obtain the results in writing; and the nurse on duty is
able to ascertain no noticeable medical problems.
2. Any physical examination not performed by the Gaudenzia physician will be
reviewed and signed off by him/her within 24 hours of client's admission to the residential program.
3. Pennsylvania CBH clients are to have a completed physical within 72 hours-exceptions are
holiday or weekend.
Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological sequelae of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client."
Client # 1 was admitted January 24, 2011. The physical examination was completed December 22, 2010, but did not include the physician's overall impression of the client and a Gaudenzia physician's signature as indicated in the facility's policy and procedures as of June 2, 2011.
Client # 2 was admitted April 4, 2011; however, client # 2's record did not include documentation of a physical examination as of June 2, 2011.
Client # 3 was admitted February 9, 2011. The physical examination did not include a date of completion, a review of organ systems, general appearance, physician's overall impressions, and signature of a physician as indicated in the facility's policy and procedures as of June 2, 2011.
Client # 4 was admitted March 28, 2011. The physical examination was completed February 11, 2011, but did not include the physician's overall impression of the client as indicated in the facility's policy and procedures as of June 2, 2011.
During ongoing dialogues with the facility director conducted on June 1, 2011 from approximately 10:30 A.M. to 3:45 P.M. and conducted on June 2, 2011 from approximately 8:30 A.M. to 1:00 P.M., it was confirmed that the facility did not document a physical examination in accordance with the facility's policy and procedures in client records # 1, 3, and 4. Also, during the same ongoing dialogues, it was confirmed that the facility did not document a physical examination in client record # 2.
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Plan of Correction
The policy regarding physical examinations will be ammended and a target date for approval by board will be August 16,2011,per the corporate office. This ammendment will reflect that upon admission all clients who have had a physical examination conducted by a physician other than a Gaudenzia Physician shall have the exam results sent by the Program Nurse to the Gaudenzia Physician to be reviewed within one business week. Also client records #1,2,3 and 4 can't be corrected due to clients no longer in the program(dates of discharge(6/3,6/8,6/9 and 6/10/11).
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709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of the facility's letters of agreement and an interview with the facility director, the project failed to assists clients in obtaining medical supportive services when necessary.
The findings include:
The letters of agreement were reviewed from June 1, 2011 to June 2, 2011. The facility did provide a written agreement with a medical office for medical services for clients at the facility. However, the agreement had expired on June 5, 2008.
During ongoing dialogues with the facility director conducted on June 1, 2011 from approximately 10:30 A.M. to 4:00 P.M. and conducted on June 2, 2011 from approximately 8:30 A.M. to 1:00 P.M., it was confirmed that the facility had not yet renewed their written agreement for medical services for clients at the facility. Also, during the same ongoing dialogues with the facility director, it was confirmed that the facility does not provide any onsite medical services to clients.
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Plan of Correction
Washington House has renewed its referral and supportive medical service letters of aggreements on 6/1/11 dental services and 6/6/11 medical services. The Administrative Coordinator will be responsible for requesting renewal letters of agreement for both services listed above 90 days before they expire. The Program Director will remind the Administrative Coordinator to request renewal letters of agreement 90 days before they expire. |
709.52(e)(7) LICENSURE Recreational/social supports
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(7) Recreational/social.
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Observations
Based on observations on June 2, 2011 and an interview with the facility director, the project failed to assist clients in obtaining recreational/social services when necessary.
The findings include:
A physical plant inspection was conducted on June 2, 2011 from approximately 1:30 P.M. to 2:30P.M. During the inspection, the Licensing Specialist asked the facility director to show him an area onsite in which the facility provides clients with recreational/social services. Also, from June 1, 2011 to June 2, 2011, the Licensing Specialist asked to see documentation that the facility assists clients in obtaining recreational/social services when necessary. The facility director was unable to show the Licensing Specialist an area onsite in which the facility provides clients with recreational/social services. In addition, documentation that the facility assists clients in obtaining recreational/social services was not presented for review.
An interview with the facility director conducted on June 2, 2011 at approximately 2:35 P.M. confirmed that the facility does not have an area onsite that provides clients with recreational/social services. Also, during ongoing dialogues with the facility director conducted on June 1, 2011 from approximately 10:30 A.M. to 3:45 P.M. and conducted on June 2, 2011 from approximately 8:30 A.M. to 1:00 P.M., the facility director stated that the facility takes clients on field trips to plays and other recreational/social events. However, during the same ongoing dialogues, it was confirmed that the facility does not have any documentation showing that the facility takes clients on field trips to plays or any other documentation that assists clients in obtaining other recreational/social services when necessary.
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Plan of Correction
All Washington House clients have attended Fun Fridays at the local community center at 1701 W. Lehigh Avenue since the closing of the recreation center where the Saturday night dances were held. July 8, 2011 was the first Fun Friday. Clients will attend the next Fun Friday on July 29,2011. The clients will attend Fun Fridays on the first and last Friday of each month. A record will be kept stating the day,date and location of the dance. All Washington House clients will attend a nine week cycle rotation of social services that will be provided by outside community services organization. The Clinical Supervisor will be responsible for making sure that there is no lapse in in the cycle rotation.She will make contact with the outside community organization within 30 days prior to the cycle of services ending;Clinical Supervisor will report to Program Director immediately after contacting community organization to say when the new date for outside social services will begin. Director will monitor Clinical Supervisor to ensure that recreational and social services occurr as scheduled. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and an interview with the facility director and clinical supervisor, the facility failed to verify that work done by the client at the project is an integral part of his treatment and rehabilitation plan in four of four records reviewed.
The findings include:
From June 1, 2011 to June 2, 2011, four records were reviewed for documentation for verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan. The facility did not document verification of work therapy in the comprehensive treatment plan or treatment plan updates in client records # 1, 2, 3, and 4.
Client # 1 was admitted January 24, 2011. The comprehensive treatment plan was completed January 25, 2011. Also, the treatment plan updates were completed on February 24, 2011; March 24, 2011; April 22, 2011; and May 20, 2011. However, client # 1's record did not include documentation of work therapy in the comprehensive treatment plan or treatment plan updates.
Client # 2 was admitted April 4, 2011. The comprehensive treatment plan was completed April 5, 2011 and the treatment plan update was completed May 5, 2011. However, client # 2's record did not include documentation of work therapy in the comprehensive treatment plan or treatment plan update.
Client # 3 was admitted February 9, 2011. The comprehensive treatment plan was completed February 10, 2011. Also, the treatment plan updates were completed on March 10, 2011; April 8, 2011; and May 5, 2011. However, client # 3 ' s record did not include documentation of work therapy in the comprehensive treatment plan or treatment plan updates.
Client # 4 was admitted March 28, 2011. The comprehensive treatment plan was completed March 30, 2011. Also, the treatment plan updates were completed on April 29, 2011 and May 26, 2011. However, client # 4's record did not include documentation of work therapy in the comprehensive treatment plan or treatment plan updates.
During ongoing dialogues with the facility director and clinical supervisor conducted on June 1, 2011 from approximately 10:30 A.M. to 3:45 P.M. and conducted on June 2, 2011 from approximately 8:30 A.M. to 1:00 P.M., it was confirmed that the facility did not document verification of work therapy in the comprehensive treatment plan or treatment plan updates in client records # 1, 2, 3, and 4.
This is a repeat citation. The facility was cited on June 9, 2010 for failing to verify that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
The facility's Plan of correction for the citation for the June 9, 2010 citation was as follows:
"Work therapy is an essential part of a client's development during their stay in a therapeutic community. One counselor did have work therapy on her treatment plans, unfortunately the other counselors did not. Leslie Ziegler, Program Director at Winner and previous Director at Washington House will do a training with Washington House's clinical staff to insure that work therapy is a goal on every treatment plan. Training will occur on 7/1/2010. Patricia Evans, Clinical Supervisor at Washington House will review each update monthly and insure work therapy is a goal. If work therapy is not on the update, it will not be signed off on and will be given back to the counselor to add. This begins with all treatment plans scheduled to be updated in July, 2010."
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Plan of Correction
The Clinical Supervisor will meet with each counselor monthly, to review and ensure that everyone on each counselor's caseload has work therapy. Work therapy will be documented on each comprehensive and updated treatment plan.Program Director will meet with Clinical Supervisor monthly to ensure that all treatment plans include work therapy and to prevent thia area from becoming a citation in the future. Client records # 1,2,3, and 4 can not be adjusted; the clients for charts #1,2,3, and 4 have been discharged from treatment(completed teartment/ left against staff advice)on or before June 10,2011 |
709.54(c) LICENSURE Follow-up policy
709.54. Project management services.
(c) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a written client follow-up policy that accurately reflects their follow-up process.
The findings include:
From May 9, 2011 through May 11, 2011, the facility's policy and procedure manual was reviewed. The facility had two conflicting procedures regarding attempts to follow up on clients.
The facility's policy titled: "Follow Up Information," states:
"All clients are followed up after discharge.
Follow up information shall be conducted for each client after discharge from the program, unless there is specific client refusal for follow up. Each program will maintain a follow up policy outlining the specific steps taken. The follow up log binder will house the documentation of each follow up attempt.
Primary Counselors and/or any designee of the Program/Clinical Supervisor or Director shall assume responsibility for client follow up.
In the case where a client has been referred to a specific outside resource for continued care post discharge from the project, follow up should be completed via a telephone call with the resource within one week of the client's initial referral appointment to the resource. Once the attempt has been made and documented in the follow up log binder, a program may consider its obligation to the individual fulfilled. This procedure will follow for client ' s who are nor referred after discharge. The worker will attempt to contact the client directly via telephone and document the findings in the log binder.
In instances where the client refuses follow up, the refusal shall be documented on the Follow Up form and in a progress note [remember to state the reason for the refusal in the note and on the form].
Where clients are not referred after discharge, the clinical supervisor or their designee will call the client in 30 days. Contact will be logged in the Follow Up Log binder.
.Follow up information shall include the client's status with the referral resource/resource disposition, sobriety status, 12 step/support group involvement, and overall progress with aftercare goals."
The facility's policy and procedure manual contained a second written policy titled: "FOLLOW UP INFORMATION." This second policy states: "Regardless of the type of discharge, attempts are made to followed up all clients post discharge. When a client has been discharged and referred to an outside source, the program will, with the written consent of the client and within one week from the day the referral is to be completed, attempt to determine from the resource the disposition of the referral. Once the attempt has been made and documented in the follow up log book, the program may consider its obligation to the individual fulfilled. The administrative assistant or designee by the program supervisor. When the client refuses a referral after discharge (this includes ASA, Therapeutic Discharge or completions who refuse the next level of care on the continuum), an attempt will be made by the administrative assistant or supervisor's designee, to follow-up the discharged client's progress and well being and to maintain an opportunity for either re-admission to the program or admission to the next level of care on the continuum should circumstances warrant it as necessary and appropriate. This will occur within the 7 days post discharge. Information shall be kept in the follow up log binder."
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Plan of Correction
The "Follow Up Policy" for all Gaudenzia programs has been ammended. The Director of Continous Quailty Improvement(CQI)has re-written the "Follow Policy".The policy has been approved and is now being implemented. The Policy was re-written June 2011.The Director of CQI will be responsible for monitoring the policy to ensure that this does not become a deficiency in the future. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction (POC) approved by the Department.
The findings include:
On June 2, 2011 the facility was again found to be out of compliance with the following standards:
1. 709.53(a)(12) Client records. 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: Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
The facility was previously cited for noncompliance with this standard during the licensing inspection conducted on June 9, 2010 (plan of correction submitted on 7/1/2010 and approved on 7/8/2010).
2. 704.11(f)(2) Staff development program. Training requirements for counselors. Each counselor shall complete at least 25 hours of training annually.
The facility was previously cited for noncompliance with this standard during the licensing inspections conducted on June 9, 2010 (plan of correction submitted on 7/10/2009 and approved on 7/16/09) and March 14, 2006 (plan of correction approved on 5/13/2006).
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Plan of Correction
Plan of Correction (response to citation #A040#1):
The Clinical Supervisor will meet with each counselor monthly, to review and ensure that everyone on each counselor's caseload has work therapy. Work therapy will be documented on each comprehensive and updated treatment plan. Program Director will meet with Clinical Supervisor monthly to ensure that all treatment plans include work therapy and to prevent this area from becoming a citation in the future. Client records # 1, 2, 3, and 4 can not be adjusted; the clients for charts #1, 2, 3, and 4 have been discharged from treatment (completed treatment/ left against staff advice) on or before June 10, 2011; #709.53A12 ? Facility will comply with all plan of corrections and dates that are to be in compliance as approved by the Department of Health unless the facility requests an extension or a modification has been requested by the facility and/or the Department of Health.
Plan of Correction (response to citation #A040#2):
An individual training plan was completed for each employee. The adminstrative coordinator will review each employee record to ensure training hours compliance. The program director will review training hours with administrative coordinator quarterly to ensure training compliance for staff. Facility director will be responsible for monitoring those dates to comply with the different Department Heads for updates on staff trainings and dates trainings were attended. #704.11F2
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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 the facility's Staffing Requirements Facility Summary Report form and personnel information, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS within the first year of employment for clinical staff and within two years of employment for non-clinical staff in one of one records reviewed.
The findings include:
From June 1, 2011 to June 3, 2011, the facility's Staffing Requirements Facility Summary Report form was reviewed for documentation of HIV/AIDS training. Also, on June 3, 2011 a copy of employee # 7's medical license, resume, and other personnel information was reviewed to determine if employee # 7 received HIV/AIDS training.
Employee # 7, the program psychiatrist, was hired August 7, 2007, HIV/AIDS training was due August 7, 2009. However, the Staffing Requirements Facility Summary Report form completed by the facility on June 1, 2011 did not include documentation that employee # 7 completed HIV/AIDS training. Also, the resume of employee # 7 indicated that employee # 7 graduated medical school May 1991.
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Plan of Correction
Employee #7 will obtain his HIV/AIDS certification through the Gaudenzia Training Institute within 30 days of today's date June 29,2011. Program Director will meet with employee # 7 quarterly to make sure state regulations are met as well as ensure future citations in this area don't occur.Program director will monitor the training needs for all staff and will arrange for staff to attend required traings to ensure that this area does not result in future deficiencies. |
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 review of personnel records and an interview with the virtual learning manager, The facility failed to ensure that each counselor completed 25 clock hours of required training in one of one personnel record reviewed.
The findings include:
On May 11, 2011, one personnel record was reviewed at the facility's corporate office for documentation of the required 25 hours of training. The facility failed to document 25 clock hours of training in personnel record # 6.
Employee # 6, a counselor, was hired November 30, 2009. The facility's training year is from January through December. The training year for January 1, 2010 to December 31, 2010 was reviewed. Personnel record # 6 only had documentation of 6 clock hours of training for the January 1, 2010 to December 31, 2010 training year as of May 11, 2011.
During an ongoing dialogue with the virtual learning manager conducted on May 11, 2011 from approximately 9:00 A.M. to 2:30 P.M., it was confirmed that personnel record # 6 only had documentation of 6 clock hours of training for the January 1, 2010 to December 31, 2010.
This is a repeat citation. The facility was cited on June 9, 2009 and March 14, 2006 for failing to ensure that each counselor complete 25 clock hours of required training.
The facility's Plan of correction for the citation for the June 9, 2010 citation was as follows:
"Clinical Supervisor will review counselor training hours quarterly for compliance. Program Director will review with Supervisor semi-annually. This will begin by 7/30/09."
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Plan of Correction
The staff person identified as "employee number # 6" attended Relapse Prevention Training 7/14/11- 6hrs.,Overview of Substance Abuse on 7/19 and 7/20/11- 12hrs,Gender Specific(trauma informed training)3/17/11 to 3/18/11- 12hrs. Employee # 6 and all other clinical staff will also attend a training on 8/26/11 which will give all clinical staff the required hours of training. The Administrative Coordinator will examine personnel folders monthly to ensure that all staff have required training hours. All counselors will complete 25 hours of training by the end of the year, 12/31/2011. The administative coordinator will also contact Gaudenzia Training Institute staff to make sure that each staff person has the correct number of training hours to avoid futre citations in this area. Program Director will meet with her monthly to monitor staff personnel charts for compliance with traing hours. |