INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10-11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, Inc. West Chester 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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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based upon the review of Administrative documentation, the project failed to have an independent annual audit of financial activities associated with the project's drug/alcohol abuse services completed upon conclusion of the fiscal year.
The findings include:
Licensing Staff conducted an Administrative Review from May 7 - 9, 2012.
Administrative documentation specified that the fiscal year runs from July 1 to June 30. However, the project's annual fiscal audit was late as it was completed February 20, 2012.
The findings were reviewed during the exit interview for the Administrative Review and were not disputed.
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Plan of Correction
At the most recent Audit Committee meeting, the necessity that all future financial audits must be completed within required timeframes was reinforced with the external independent public accountant. These timeframes were acknowledged by the independent public accountant and recorded in the meeting minutes. The Director of Finance and Accounting will maintain oversight throughout the auditing process to ensure completion in a timely manner." The Financial Audit for Fiscal Year 2011-2012 will be completed within 6 months after the June 30th close of Gaudenzia's fiscal year (by December 31st, 2012) as per Chapter 709.25(a).
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial assessment and/or failed to document a psychosocial assessment that included the client's composite picture, assets and strengths, coping mechanisms, and/or negative factors that could interfere with treatment.
The findings include:
Seven client records requiring psychosocial evaluations were reviewed on May 10, 2012. x out of seven client records lacked documentation of a clinical assessment, specifically client records # 2, 3, 4, 5, 6, and 7.
Client #2 was admitted to treatment on March 15, 2012. The psychosocial evaluation was completed on March 16, 2012 and did not include a clinical assessment of the client's composite picture, assets and strengths, coping mechanisms, and negative factors that could interfere with treatment.
Client #3 was admitted to treatment on March 16, 2012. The psychosocial evaluation was completed on March 16, 2012 and did not include a clinical assessment of the client's composite picture and assets and strengths.
Client #4 was admitted to treatment on February 10, 2012. The psychosocial evaluation was completed on February 10, 2012 and did not include a clinical assessment of the client's composite picture.
Client #5 was admitted to treatment on January 6, 2012 and discharged on February 21, 2012. The psychosocial evaluation was completed on January 9, 2012 and did not include a clinical assessment of the client's composite picture.
Client #6 was admitted to treatment on December 8, 2011 and discharged on March 9, 2012. The psychosocial evaluation was completed on December 8, 2011 and did not include a clinical assessment of the client's composite picture.
Client #7 was admitted to treatment on January 23, 2012. The psychosocial evaluation was completed on January 23, 2012 and did not include a clinical assessment of the client's composite picture, assets and strengths, coping mechanisms, and negative factors that could interfere with treatment.
The findings were confirmed with the facility director.
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Plan of Correction
An in-service training has begun with the Clinical Supervisor, Program Supervisor, and all Clinical Staff of GHWC in order to provide all participants with knowledge/skills to effectively and adequately complete the psychosocial assessment. Special emphasis will be placed on increasing the counselor's abilities to gather the historical information, but also on summarizing that information and assessing the individual to paint a composite/complete picture of the individual in treatment. This training has been divided into 3 sessions (6/6, 6/20, and 7/11) and is mandatory for all participants listed above to attend. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 client records, the facility failed to ensure counseling services were provided according to the clients' individual treatment and rehabilitation plan.
The findings include:
Seven inpatient records requiring documentation of treatment services were reviewed on May 10, 2012. The facility failed to ensure that services were provided in accordance with the clients' individual treatment plans in three out of seven inpatient client records, specifically #s 2, 3 and 6.
Client #2 was admitted on March 15, 2012. The client's individual treatment plan documented on March 16, 2012, stated that the client shall receive one individual session a week and five, group sessions a week. The client's last documented service was on April 13, 2012. Over three weeks had passed without any documentation of client #2 participating in an individual or group session.
Client #3 was admitted on March 16, 2012. The client's individual treatment plan documented on March 16, 2012, stated the client shall receive one individual session a week and five group sessions a week. The client's record included documented weekly individual counseling sessions from 3/16/12 to 4/20/12 and two groups counseling sessions on 3/26/12 and 4/23/12. Over two weeks had passed without any documentation of client # 3 participating in an individual or group session.
Client #6 was admitted on December 8, 2011 and discharged on March 9, 2012. The client's individual treatment plan documented on December 8, 2011, stated that the client shall receive one individual session a week and five, group sessions a week. The client's treatment plan update was documented on January 9, 2012 and did not indicate a specific type and frequency of service. The February 9, 2012 treatment plan update stated that the client shall receive one individual session a week and five, group sessions a week. The client's last documented service was on January 19, 2012. Over six weeks had passed without any documentation of client #6 participating in an individual or group session.
The findings were discussed with the lead counselor and facility director prior to the exit interview.
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Plan of Correction
The Clinical Supervisor is responsible for the systematic collection, review, and analysis of all clinical documentation for the services that are provided within the program.
In reference to this citation, Clinical Supervisor will increase his/her reliance on the abovementioned system. Program Director has increased her supervision with the Clinical Supervisor from a monthly to a weekly basis. This change in the frequency of supervision has enabled Program Director to review the progress of Clinical Supervisor's ability to collect, review, and analysis all clinical documentation for the services provided on a weekly basis. Program Director will also utilize progressive behavior interventions, if needed, with his/her subordinates to assist his/her subordinates with meeting the established deadlines.
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709.53(a)(3) LICENSURE Records of Service
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a chronological listing of the various specific services provided to each individual.
The findings include:
Seven inpatient records requiring documentation of a record of service were reviewed on May 10, 2012. The facility failed to document services as provided to the clients in six out of seven client records, specifically #'s 1, 2, 3, 4, 5, and 6.
Client #1 was admitted to treatment on March 7, 2012. There was no documentation of a record of service in the record for client #1.
Client #2 was admitted to treatment on March 15, 2012. There was no documentation of a record of service in the record for client #2.
Client #3 was admitted to treatment on March 16, 2012. There was no documentation of a record of service in the record for client #3.
Client #4 was admitted to treatment on February 10, 2012. There was no documentation of a record of service in the record for client #4.
Client #5 was admitted to treatment on January 6,2012 and discharged on February 21, 2012. There was no documentation of a record of service in the record for client #5.
Client #6 was admitted to treatment on December 8, 2011 and discharged on March 9, 2012. There was no documentation of a record of service in the record for client #6.
The lead counselor and facility director were asked to provide documentation of a record of service, however it was not produced. The lack of documentation was confirmed with the facility director prior to the exit interview.
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Plan of Correction
An in-service training with the Clinical Supervisor, Program Supervisor, and all Clinical Staff of GHWC will be held in order to provide all participants with knowledge/skills to effectively and adequately complete the Record of Services.
In addition to that, Clinical Supervisor will establish a system that will include collecting, reviewing, and analyzing the Record of Services from all counselors for the preceding month. The established date for this submission will be the first Wednesday of each month. Program Director will ensure that this system is being followed through on during weekly meeting with Clinical Supervisor.
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of staff training records, the facility failed to ensure clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision.
The findings include:
Three personnel records were reviewed for the position of clinical supervisor and lead counselor on May 8, 2012. The facility failed to provide a core curriculum in clinical supervision for one out of three of those employees. Employee # 3 was hired as a clinical supervisor on October 11, 2011. After a review of employee #3's resume, it was found they had less than two years experience as supervisor in a clinical setting. Employee #3's personnel record did not have documentation of a core curriculum in clinical supervision.
These findings were confirmed with human resources specialist during the administrative review.
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Plan of Correction
Clinical Supervisor has been scheduled to attend the next DOH Clinical Supervision Core Curriculum Training, which is scheduled to begin in December. Program Director and Administrative Coordinator will be the responsible parties to ensure that the current Clinical Supervisor is enrolled and attends the abovementioned training.
In the event of that GHWC is soliciting candidates to fulfill a vacancy in the Clinical Supervisor position; Program Director will be the responsible party to thoroughly screen all resumes for potential candidates. Program Director will be screening the resumes to ensure that all candidates have served in a Clinical Supervisory position in a drug and alcohol setting for a period of at least 2 years prior to the candidate even being considered as a viable applicant for the position.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document individual training plans in accordance with facility policy.
The findings include:
On May 8, 2012 employee # 1's personnel record was reviewed for documentation of an individual training plan.
The project failed to develop an individual training plan annually in accordance with policy.
The facility's policy titled "Plan for Assessment of Staff Training Needs" states:
In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year.
Employee # 1 has been the project director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
This is a repeat citation. The Project was previously cited for noncompliance with this standard during the 2011 licensure inspection.
The findings were reviewed with the human resources staff.
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Plan of Correction
The Training Department will ensure that an individual training plan is developed and documented for all employees within required timeframes. A reminder of the January 31st deadline for completion will be forwarded to all Managers during the 1st week of December. In addition, the Training Department will coordinate with the Executive Assistant to ensure that development of an Individual Training Plan for the Project Director is a specific agenda item during the Project Director's meeting with the Chairman of the Board during the month of December. A current, signed Individual Training Plan is presently in the Project Director's file." Individual Training Plans will be completed for all employees by January 31st, 2013 as per our policy.
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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 staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
One personnel record for a Counselor Assistant, employee #8, requiring documentation of HIV/AIDS and TB/STD training was reviewed on May 8, 2012. One out of one record, specifically record # 8, did not contain the required documentation. Employee # 8, a counselor assistant, was hired on March 14, 2011. Training was due by March 14, 2012. As of the licensing inspection, there was no documentation of TB/STD training for employee #8.
The findings were confirmed with the training director during the administrative review and again with the facility director on May 11, 2012
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Plan of Correction
The identified staff member had been scheduled for this training twice in the past, however, this training had been cancelled within the agency, which hindered her from being able to complete it. In addition to that, this counselor has been scheduled to attend the next approved training, which is scheduled July 19, 2012. Program Director, Clinical Supervisor, and Administrative Coordinator will ensure that this staff member attends this training.
In order to prevent this deficiency from reoccurring, Administrative Coordinator will review and monitor all personnel folders to ensure compliance with the standards. Furthermore, in the event that the above training is cancelled by the Training Institute, Administrative Coordinator will solicit alternative approved trainings to enroll staff members in to avoid this deficiency and ensure compliance with standards.
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704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form (page 5) completed by the facility director on May 10, 2012, the facility failed to ensure that the staff to client ratios remained at or below 8:1.
The findings include:
Page 5 of the Staffing Requirements Facility Summary Report form completed by the facility was reviewed on May 10, 2012. The form listed the facility director, two clinical supervisors, four counselors and one counselor assistant for the clinical staff.
The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of current clients as of May 10, 2012 exceeded the allowable maximum of 8:1.
The actual client ratio is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients treatment by the facility's standard work week.
The number of hours per week was 217 hours. 217 divided by the facility work week of 40 hours equals 5.425 FTE. The number of current clients is 53 divided by the 5.425 FTE is 9.76, this results in a ratio of 10:1 which exceeds the maximum of 8:1.
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Plan of Correction
The following two steps will assist us in correcting the deficit and give us the ability to prevent this crisis from happening again: the facility has contracted with a staffing agency, Staffing Plus, they will provide temporary staff to assist us when we fall into this type of dilemma. After a specified time frame these individuals may have the option to become regular staff.
Secondly, the facility will reach out to other facilities in the agency to borrow staff to fill vacant positions, until we can hire staff to fill them.
The Program and Clinical Supervisors will work closely together on a weekly/biweekly basis to ensure that the client/staff ratio in being met.
GHWC is in the process of soliciting viable candidates to fulfill some of the vacancies that are held within the Clinical Department. It is expected that all positions will be filled within the next 90 days and the FTE/client ratio will be adjusted to be within compliance.
In addition to that, resumes continue to be reviewed and interviews are scheduled. Program anticipates the hiring of a counselor and having this individual begin employment on 7/2/12.
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