INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 5, 2012 licensure renewal inspection. The follow-up inspection was conducted on November 5, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Gaudenzia at Sunbury 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(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based upon a review of the project's Policy & Procedure (P&P) Manual, the project failed to adopt consistent policies for individualized treatment and rehabilitation plans. The facility had policies for treatment plans that were contradictory.
The findings include:
The P&P Manual was reviewed during an administrative review from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) within 3-5 client days residential..."
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service, within 3 days of admission (residential)..."
The first policy allows five days to complete the individualized treatment plan while the second policy stipulates it must be completed within three days.
Regarding outpatient facilities, the policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"An individual treatment and rehabilitation plan will be developed with each client after the completion of the client's psychosocial evaluation."
The policy titled, "Intake Process/Paperwork" Treatment Plan included the following language:
"Based on the psychosocial assessment, the Counselor shall formulate an individualized treatment plan ..."The individualized treatment plan shall be completed, approved and signed by the Counselor, Clinical Supervisor and Medical Director (when applicable) ... by the second or third counseling outpatient appointment....."
The policy titled, "Intake Process/Paperwork" Psychosocial Assessment stated:
Upon completion of the psychosocial histories...The assessment shall be submitted promptly ... to the Clinical Supervisor for review and signature ... within 3 individual sessions for outpatient.
The policy titled, "Individual Treatment Plan" Individual Treatment and Rehabilitation Plan included the following language:
"Completion of the treatment plan will be noted in the counselor's progress note for that day of service,... by the third session (outpatient)..."
Each policy relating to the completion of the treatment plans for outpatient contained statements that require the treatment plan be completed in three sessions (regardless of being individual or group) while there are other statements that would indicate that the treatment plan would not be required or allowed to be completed until the third individual session based on the completion of the psychosocial assessment.
The facility was previously cited on June 5, 2012, for which a plan of correction was submitted and approved on July 2, 2012. The response states:
" The relevant policies in the Gaudenzia Policy and Procedure manual will be revised by the Quality Improvement Director to ensure consistency and clarity, and to meet all relevant State, Accreditation, and Funding requirements. Changes to these policies will be reviewed and approved by the Board of Directors. These changes will be reviewed with clinicians at each facility ' s staff meetings by the Program Director and/or Program Supervisor in order to ensure full understanding and ongoing compliance. Program Supervisors will monitor timely completion of Initial Treatment Plans as part of regular clinical chart reviews, and the findings of these reviews will be discussed in regular clinical supervision as well as staff meetings and monthly CQI analysis. These policies will be revised and approved by July 31st, 2012.
During an interview with the facility director on November 5, 2012, she had advised that her facility did not receive any documentation or notification of a policy revision.
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Plan of Correction
The revelant policies in the Gaudenzia policy and procedure manual was revised in July by the Quality Improvement Director to ensure consistency and clarity and to meet all relevant State, Accreditation and funding requirements. These changes were received and reviewed by the Division Director on 11-6-12 and presented to clinical staff during clincial meeting held December 14, 2012 by the Clinical Supervisor. The Program Director and/or Clinical Supervisor will monitor monthly for ongoing compliance. Timely completion of treatment plans will be part of weekly clinical meetings as well as staff supervisory sessions. CQI analysis will occur monthly. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based upon a review of the facility's policies and procedures and client records, the facility failed to document case consultations as per their policy.
The findings include:
The policies and procedures manual was reviewed as part of an administrative review that was conducted from May 1 - 2, 2012.
The policy titled, "Intake Process/Paperwork" included the following language, which specified the timeframe for the completion of case consultations:
" Case Consults are performed every 90 days for outpatient. Case Consults are performed more frequently whenever a client has a special problem (s). The Counselor shall meet with the Clinical Supervisor on a regular scheduled basis, i.e., weekly or bi-weekly, to discuss the overall progress or problems of each client. Documentation of the case consults shall be completed by the primary Counselor. "
Five client records requiring documentation of case consultations were reviewed on November 5, 2012. Three out of five client records, did not have documentation of a case consultation, specifically #'s 3, 4, and 5
Client #3 was admitted into treatment on July 3, 2012. A case consultation was due by October 3, 2012 for client #3. As of the date of inspection, there was no documentation of a case consultation for client #3.
Client #4 was admitted to treatment on July 4, 2012. A case consultation was due by October 4, 2012 for client #4. As of the date of inspection, there was no documentation of a case consultation for client #4.
Client #5 was admitted to treatment on July 3, 2012. A case consultation was due by October 3, 2012 for client #5. As of the date of inspection, there was no documentation of a case consultation for client #5.
The findings were reviewed with the facility director during the exit interview.
This is a repeat citation. The facility was previously cited for noncompliance with this standard on June 5, 2012.
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Plan of Correction
The treatment management procedures will be reviewed with clinical staff by the Clinical Supervisor in clinical meeting scheduled to be held on December 14, 2012. All staff will be reminded that case consults are due every 90 days for each client. During the administrative meeting on November 8, 2012 a change in procedure was discussed between the Administrative Coordinator, Clinical Supervisor and the Division Director. The new procedure includes: all case consult documentation be brought to clinical meeting every Friday and completed during the meeting. This information was provided to the clinical staff by the Clinical Supervisor during an all staff meeting held on November 16, 2012. The Program Director will review compliance through the CQI process monthly. The Clinical Supervisor will review census weekly to determine those case consults due for completion. |