INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Outpatient was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) form initially completed by the facility on March 14, 2014 and updated on May 8, 2014, the facility failed to ensure that full-time equivalent (FTE) counselor caseloads remained at or under 35:1 for two of ten counselors.
The findings include:
A counselor's FTE is calculated by dividing the number of hours per week that are devoted to client treatment by the standard work week.
The standard work week used to calculate FTE counselor caseloads is 35 hours per week.
FTE counselor caseloads are then calculated by dividing the actual number of clients assigned to a counselor by the counselor's FTE.
On March 14, 2014 and May 8, 2014, the SRFSR forms completed by the facility were reviewed. The facility failed to ensure that employees # 3 and 5 did not exceed an FTE counselor caseload of 35 active clients as of May 8, 2014.
The facility reported on the SRFSR form that employee # 3 had 47 active clients on May 8, 2014. The number of hours per week devoted by employee # 3 to client treatment, as reported by the facility, was 37.5 hours per week. Employee # 3's FTE was as follows: 37.5 hours per week / 35 hour standard work week = 1.0714 FTE. Employee # 3's FTE counselor caseload was as follows: 47 clients / 1.0714 FTE = 44:1. Counselor # 3 exceeded the maximum of a 35:1 FTE counselor caseload.
The facility reported on the SRFSR form that employee # 5 had 44 active clients on May 8, 2014. The number of hours per week devoted by employee # 5 to client treatment, as reported by the facility, was 37.5 hours per week. Employee # 5's FTE was as follows: 37.5 hours per week / 35 hour standard work week = 1.0714 FTE. Employee # 5's FTE counselor caseload was as follows: 44 clients / 1.0714 FTE = 41:1. Counselor # 5 exceeded the maximum of a 35:1 FTE counselor caseload.
The findings were confirmed during an interview with the facility director on May 8, 2014 at approximately 8:30 A.M.
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Plan of Correction
Effective June 1, 2014, the Program Director, Program Supervisor and Administrative Manager will review the current census on a weekly basis to monitor compliance with the 35:1 ratio.
Employees #3 and #5 now have a caseload of no more that 35 active clients.
Counselors with higher caseloads will not be assigned additional clients and current caseloads will be shifted to counselors with fewer than the 35:1 ratio requirement. These shifts will be completed by June 3, 2014.
The Program Supervisor will monitor client caseloads in supervision to determine clients that need to be discharged for leaving ASA or for non-compliance.
The Program Director will maintain oversight. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on an observation on May 8, 2014, the facility failed to ventilate bathrooms by an exhaust fan or window in one of three bathrooms.
The findings include:
A physical plant inspection was conducted on May 8, 2014. The facility maintained 1 unisex client bathroom, 1staff bathroom, and 1 unisex public bathroom. The unisex client bathroom on the first floor was not ventilated by an exhaust fan or window at the time of inspection.
The findings were confirmed during an interview with the facility director on May 8, 2014 at approximately 12:36 P.M.
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Plan of Correction
The Program Director met with the Central Region Physical Plant Manager on May 20, 2014 to discuss the need for the exhaust fan to be in working order in the unisex client bathroom on the first floor.
Repairs will be made by June 30, 2014 to install a new exhaust fan in working order into the unisex client bathroom on the first floor.
Daily inspections of the bathrooms will be conducted by the Program Supervisor or Program Director on the first floor, basement bathroom and staff bathroom to ensure they are ventilated by an exhaust fan or window
The Program Director will monitor physical plant compliance through biweekly inspections of the facility and needs will be reported in monthly Maintenance Meetings with the Regional Director, Central Region Director, Physical Plant Manager and Program Director. |
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 review and sign off on client histories, to include the medical, drug or alcohol and personal history, completed within six months prior to admission by the SCA or other D & A treatment facility, in three of ten client records reviewed. The facility also failed to document a client history, to include the medical, drug or alcohol and personal history, in two of ten client records reviewed.
The findings include:
On May 8, 2014, ten client records requiring documentation of client histories were reviewed. The facility failed to review and sign off on client histories obtained from a licensed drug and alcohol treatment provider or the Single County Authority in client records # 3, 5, and 6 and failed to document a client history in client records # 7 and 10.
Client # 3 was admitted November 19, 2013. The client history dated October 23, 2013 was provided by an outside agency. However, the client history did not include documentation of a signature from the new counselor indicating that the history was reviewed as of May 8, 2014.
Client # 5 was admitted December 19, 2013. The client history dated September 13, 2013 was provided by an outside agency. However, the client history did not include documentation of a signature from the new counselor indicating that the history was reviewed as of May 8, 2014.
Client # 6 was admitted October 16, 2013. The client history dated October 1, 2013 was provided by an outside agency. However, the client history did not include documentation of a signature from the new counselor indicating that the history was reviewed as of May 8, 2014.
Client # 7 was admitted February 10, 2014. The client history was due March 12, 2014. However, client record # 7 did not include documentation of a client history as of May 8, 2014.
Client # 10 was admitted September 10, 2013. The client history was due October 10, 2013. However, client record # 10 did not include documentation of a client history as of May 8, 2014.
The findings were confirmed during an interview with the facility director and clinical supervisors on May 8, 2014 at approximately 3:45 P.M.
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Plan of Correction
The client histories obtained from a licensed drug and alcohol treatment provider or the Single County Authority (SCA) in client records #3, 5 and 6 have now been reviewed and signed off by the client and counselor for each record.
Effective immediately, the Program Director and Clinical Supervisor will ensure that the biopsychosocials will be completed and/or reviewed within thirty (30) days of admission or at the evaluation session, whichever is applicable. Notations will be made on each page of the biopsychosocial with staff initials and the date(s) of the review if a biopsychosocial is being utilized from another D&A agency or within six (6) months of an evaluation. Another assessment will be completed upon review for histories that were received within six (6) months of admission either internally or externally.
This compliance will be monitored by the supervisor(s)in weekly supervisory sessions and monthly chart audits.
Additionally, the Program Director will be responsible for the oversight of compliance with this standard. |
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 five of ten client records reviewed.
The findings include:
On May 8, 2014, ten client records requiring documentation of a psychosocial evaluation were reviewed. The facility failed to document a psychosocial evaluation in client records # 3, 5, 6, 7, and 10.
Client # 3 was admitted November 19, 2013. The psychosocial evaluation was due December 19, 2013. However, client record # 3 did not include documentation of a psychosocial evaluation as of May 8, 2014.
Client # 5 was admitted December 19, 2013. The psychosocial evaluation was due January 20, 2014. However, client record # 5 did not include documentation of a psychosocial evaluation as of May 8, 2014.
Client # 6 was admitted October 16, 2013 and discharged May 7, 2014. The psychosocial evaluation was due November 15, 2013. However, client record # 6 did not include documentation of a psychosocial evaluation as of May 8, 2014.
Client # 7 was admitted February 10, 2014. The psychosocial evaluation was due March 12, 2014. However, client record # 7 did not include documentation of a psychosocial evaluation as of May 8, 2014.
Client # 10 was admitted September 10, 2013 and discharged November 21, 2013. The psychosocial evaluation was due October 10, 2013. However, client record # 10 did not include documentation of a psychosocial evaluation as of May 8, 2014.
The findings were confirmed during an interview with the facility director and clinical supervisors on May 8, 2014 at approximately 3:45 P.M.
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Plan of Correction
The biopsychosocial evaluations for clients #3,5,6,7, and 10 have now been completed and placed in each of the clients' records.
Effective immediately, the Program Director and Clinical Supervisor will ensure that psychosocial evaluations will be completed within thirty (30) days or at the initial evaluation whichever applies.
For client charts that are still active, the assessments will be completed and entered in the record by June 13, 2014.
Monthly chart audits will be conducted by the supervisor(s) and outcomes discussed in weekly clinical meeting/supervisory sessions.
The Program Director will maintain oversight of this compliance. |
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 document a complete client record on an individual that included an individual treatment and rehabilitation plan in one of ten client records reviewed, a case consultation in four of eight client records reviewed, discharge summary in one of two client records reviewed, and follow-up information in three of three client records reviewed.
The findings include:
On May 8, 2014, ten client records requiring documentation of a complete client record were reviewed. The facility failed to document a case consultation in client records # 2, 3, 4, and 6, individual treatment and rehabilitation plan in client record # 7, follow-up information in client records # 8, 9, and 10, and discharge summary in client record # 10.
Client # 2 was admitted January 14, 2014. The case consultation was due April 30, 2014. However, client record # 2 did not include documentation of a case consultation as of May 8, 2014.
Client # 3 was admitted November 19, 2013. The case consultation was due February 28, 2014. However, client record # 3 did not include documentation of a case consultation as of May 8, 2014.
Client # 4 was admitted December 2, 2013. The case consultation was due March 31, 2014. However, client record # 4 did not include documentation of a case consultation as of May 8, 2014.
Client # 6 was admitted October 16, 2013 and discharged May 7, 2014. The case consultation was due January 31, 2014. However, client record # 6 did not include documentation of a case consultation as of May 8, 2014.
Client # 7 was admitted February 10, 2014. The individual treatment and rehabilitation plan was due March 12, 2014. However, client record # 7 did not include documentation of an individual treatment and rehabilitation plan as of May 8, 2014.
Client # 8 was admitted September 19, 2013 and discharged January 21, 2014. The follow-up information was due October 19, 2013. However, client record # 8 did not include documentation of follow-up information as of May 8, 2014.
Client # 9 was admitted July 17, 2013 and discharged January 16, 2014. The follow-up information was due February 15, 2014. However, client record # 9 did not include documentation of follow-up information as of May 8, 2014.
Client # 10 was admitted September 10, 2013 and discharged November 21, 2013. The discharged summary was due November 28, 2013 and the follow-up information was due December 21, 2013. However, client record # 10 did not include documentation of a discharge summary and follow-up information as of May 8, 2014.
The findings were confirmed during an interview with the facility director and clinical supervisors on May 8, 2014 at approximately 3:45 P.M.
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Plan of Correction
Effective immediately, the following clinical documents will be completed and filed in each client record according to the listed time frames:
Treatment plans will be completed
within the required time frames;
initial(at admission session),
comprehensive (within thirty (30)
days of admission) and updates
(every thirty (30)days for IOP/SIP
and sixty (60) days for OP). The individual treatment and rehabilitation plan will be completed for client record #7.
Case consultations will be
completed every ninety (90) days.
If a client leaves prior to their
ninetieth (90)day then a case
consultation will be conducted at
discharge. Case consultations will be completed for client records #2,3,4 and 6.
Discharge summaries are to be
completed within seven (7) days
following discharge from treatment. A discharge summary will be completed for client record #10.
Follow-up information will be
completed within seven (7) days of
the date of a referral appt. made
for a client leaving treatment. In
the case of a client ending treat-
ment without a referral appt. then
the client should be contacted with-
in thirty (30) days. All follow-up
will be kept in each individual
closed file. Follow-up will be completed for client records #8,9 and 10.
The supervisor(s) will conduct caseload
reviews on a weekly basis in clinical team meeting to monitor this compliance.
QI chart audits will also be conducted monthly and outcome reviews will be made with each clinician following the week of the QI meeting.
The Program Director will be responsible for oversight of compliance with the above standards.
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