INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28 through 30, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia DRC, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on March 17, 2008.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based upon a review of personnel files, and staff schedules for the period of 12/23/2007 through 1/19/2008, on January 23 & 28, 2008, the facility failed to ensure that there was a sufficient number of staff persons with current CPR certification and first aid training onsite so that at least one person trained in these skills was present during the project's hours of operation. The facility failed to schedule a staff member with current CPR certification and first aid training on the following dates during the following hours:
12/24/07, 12/31/07, 1/7/08 and 1/14/08 from 9:00 a.m. - 10:00 a.m.
12/25/07, 12/28/07, 1/1/08, 1/4/08, 1/8/08, 1/11/08, 1/15/08 and 1/18/08 from 5:00 p.m. - 6:00 p.m.
12/26/08, 1/2/08, 1/9/08 and 1/16/08 from 5:00 p.m. - 8:00 p.m.
12/27/07, 1/3/08, 1/10/08, 1/17/08 9:00 a.m. - 10:00 a.m. and 6:00 p.m. - 8:00 p.m.
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Plan of Correction
Corrective Action:
The Program Director of the Outpatient Program will ensure that a sufficient number of Gaudenzia DRC staff persons with current CPR certification and first aid training are onsite so that at least one person trained in these skills is present during the hours of operation.
Persons Responsible:
Div. Director, Outpatient Program Dir., HR Administrator
Timeframe for Completion: March 6, 2008
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based upon a review of client records on January 30, 2008, the facility failed to ensure that consents to release information were informed and voluntary. Seven of seven records reviewed required that the revocation be in witting.
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Plan of Correction
Corrective Action:
The Division Director will revise release of information forms to reflect revocation of consent by clients "verbally". The five (5) areas of release will be specified within the document as required by Section 4 Pa. Code 255.5.
Persons Responsible:
Division Director
Timeframe for Completion: April 1, 2008.
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709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based upon a review of client records on January 30, 2008, the facility failed to ensure that consents to release information identified the information to be released. Four of seven records reviewed, #2, 3, 5 & 7, contained consents to release information that failed to include the purpose for the release.
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Plan of Correction
Corrective Action:
A confidentiality training will be facilitated to train and re-train clinical staff in the "identification, documentation and purpose" of release of information. Guidelines will be developed and attached to the release of information form for staff reference and direction.
All identified information to be released will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: April 25th 2008
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based upon a review of client records on January 29 & 30, 2008, the facility failed to provide a complete drug and alcohol history in seven of seven records reviewed. Progression of substance abuse as it relates to the lengths and patterns of abuse was not documented in seven of seven records reviewed. Client record #6 contained a section for alcohol usage that was left blank. The section for prior treatment was blank. Client record #7 documented alcohol use but failed to document the progression of substance abuse as it relates to the lengths and patterns of substance abuse. The section to document drug usage was not completed.
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Plan of Correction
Corrective Action:
A training will be facilitated to train and re-train clinical staff in the elements of the Intake Screening form and other relevant documentation. Staff will be trained to adhere to timeframes for completion of the Intake Screening and psychosocial evaluation as it relates to the lengths and patterns of abuse.
All Intake and clinical documentation will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Division Director & Outpatient Program Director
Timeframe for Completion: April 25th 2008
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based upon a review of client records on January 29 & 30, 2008, the facility failed to provide a complete personal history in seven of seven client records reviewed. Seven of seven client records reviewed contained entries for family histories which were vague and failed to provide a history of what the home of origin was like. Client record #1 was missing the personal history section all together. Client records #2 & 6 failed to provide the clients' employment histories. Client record #5 indicated that the client had been arrested, however there was no information beyond that regarding what the arrest was for or the disposition making for an incomplete legal history. Client record #6 indicated that the client had been arrested however there was no documentation if there were any open cases and the closed cases lacked documentation as to what the disposition was and where they occurred making for an incomplete legal history. Client record #7 lacked information regarding the client's recreational activities.
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Plan of Correction
Corrective Action:
A training will be conducted to train and re-train clinical staff in the elements of "psychosocial evaluation" and documentation. Staff will be trained to provide complete family, employment, and legal histories as per the Gaudenzia DRC policy statement.
All records related to client personal histories will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Division Director & Outpatient Program Director
Timeframe for Completion: April 25th 2008
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709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based upon review of client records on January 29 & 30, 2008, the facility failed to document physical examinations in two of five client records requiring physical examinations. The physical examination documentation was missing from client records #4 & 7.
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Plan of Correction
Corrective Action:
The Division Director will ensure that the Medical Director completes all client physicals and files these completed physicals in the client charts according to Gaudenzia DRC, Inc. policy. All physical examinations will be reviewed during monthly Medication Administrative Reports (MAR) and Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Medical Director and Nurse Manager
Timeframe for Completion: June 1, 2008
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based upon a review of client records on January 29 & 30, 2008, the facility failed to provide a complete psychosocial evaluation in four of seven client records reviewed, #1, 2, 6 & 7. Client records #1, 6 & 7, did not have psychosocial evaluations in the file. Client record #2 lacked a composite picture and failed to document the client's problems/needs.
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Plan of Correction
Corrective Action:
The Program Director will ensure that all client charts/files contain completed psychosocial evaluations that provide a composite picture of the client's history and document the client's problem/needs.
All documentation related to psychosocial evaluations will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Division Director & Outpatient Program Director
Timeframe for Completion: April 1, 2008
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based upon a review of client records on January 29 & 30, 2008, the facility failed to provide a comprehensive individualized treatment plan in six of seven client records reviewed, within the facility's timeframe of three treatment sessions. This was evident in client records #1, 3, 4, 5, 6 & 7. Treatment plans were not completed in client records #1, 6 & 7. Treatment plans were late for client record #3 (4th session), client record #4 (6th session) & client record #5 (7th session).
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Plan of Correction
Corrective Action:
The Program Director will be responsible for ensuring that upon completion of the intake, the counselor shall, within three (3) treatment sessions, complete an individualized treatment plan. The treatment plan shall be placed in the client file and documented on the record of service.
All documentation related to individualized treatment plans will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: April 1, 2008
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based upon a review of client records on January 29 & 30, 2008, the facility failed to identify support systems in three of four client records reviewed, #2, 4 & 5.
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Plan of Correction
Corrective Action:
The Program Director will ensure that all Individual Treatment & Rehabilitation Plans are developed with the client. Clinical staff will identify support systems to be utilized by the client.
All documentation related to Individual Treatment & Rehabilitation Plans will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: April 1, 2008
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based upon a review of client records on January 29 & 30, 2008, the facility failed to complete a treatment plan update in one of one client records requiring an update, client record #6.
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Plan of Correction
Corrective Action:
The Program Director will ensure that all Individual Treatment & Rehabilitation Plans are developed with the client and updated as required by the agency's policy manual.
All documentation related to Individual Treatment Plan Updates will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: April 1, 2008
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon a review of client records on January 29 & 30, 2008, the facility failed to provide a complete medication record documenting the medication, dosage and frequency of use, in three of four client records reviewed, #1, 6 & 7. Documentation of medication in client records #1 & 6 were not completed. Documentation of medication in client record #7 failed to include the name of the medication.
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Plan of Correction
Corrective Action:
The Program Director will ensure that all client records provide a complete medication record documenting the type of medication, dosage, and frequency of use where applicable.
All medication, dosage, and frequency documentation will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: April 1, 2008
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based upon a review of client records on January 29 & 30, 2008, the facility failed to document follow-up contact attempts in two of two client records requiring where follow-up documentation was required, client records #6 & 7.
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Plan of Correction
Corrective Action:
The Program Director will ensure that within seven (7) days of the date of a client leaving treatment, the referral shall be contacted by the Administrative Coordinator or Counselor to determine if the client kept the initial appointment and if the referral was appropriate. In the case of a client ending treatment without a referral appointment, the client shall be contacted directly to determine client well being and to maintain the opportunity for re admission should circumstances warrant it as necessary and appropriate.
All follow-up documentation will be reviewed during monthly Continuous Quality Improvement (CQI) meetings and intensively monitored for three (3) months to ensure compliance, completion, and timelines.
Persons Responsible:
Outpatient Program Director
Timeframe for Completion: April 1, 2008
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