INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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:
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Plan of Correction
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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 on a review of client records, the facility failed to document a treatment plan update at least every 60 days in five of nine client records reviewed.
The findings include:
Nine client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 5/1/2015. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 3, 5, 7 and 10.
Client # 1 was admitted on 9/23/2013 and discharged on 3/12/2015. The last two treatment plan updates for the client were completed on 12/18/2014 and 2/26/2015.
Client # 3 was admitted on 4/22/2014 and discharged on 9/22/2014. The last treatment plan update for the client was completed on 7/14/2014.
Client # 5 was admitted on 6/30/2014 and discharged on 4/17/2015. The last treatment plan update for the client was completed on 9/24/2014.
Client # 7 was admitted on 8/29/2014 and discharged on 2/9/2015. The last treatment plan update for the client was completed on 11/28/2014.
Client # 10 was admitted on 12/29/2014 and was still an active client at the time of inspection. The last two treatment plan updates for the client were completed on 1/12/2015 and 3/16/2015
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 19, 2015 to address clinical staff on treatment management procedures specific to the treatment plan update process. All staff will be directed to update treatment plans every 60 days or sooner. The Clinical Supervisor will review treatment plans for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 project failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in five of nine client records reviewed.
The findings include:
Nine client records were reviewed for counseling services on 5/1/2015. The project failed to ensure that clients received counseling services according to the client's individual treatment and rehabilitation plan in client records # 2, 3, 4, 9 and 10.
Client record # 2 contained treatment plans dated 12/15/2014 and 2/13/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. The only individual therapy sessions scheduled for the client in February 2015 through March 2015 were on 2/27/2015 and 3/13/2015.
Client record # 3 contained a treatment plan dated 7/14/2014 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client the week 9/14/2014 - 9/20/2014.
Client record # 4 contained a treatment plan dated 1/2/2015 that identified the counseling services to be provided as individual therapy sessions 2 times per month. The only individual therapy session scheduled for the client in February 2015 was on 2/9/2015.
Client record # 9 contained a treatment plan dated 2/6/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. There were no individual therapy sessions scheduled for the client in April 2015.
Client record # 10 contained a treatment plan dated 3/16/2015 that identified the counseling services to be provided as individual therapy sessions 1 time per week. The only individual therapy session scheduled for the client in April 2015 was on 4/27/2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 19, 2015 to address clinical staff on treatment management procedures specific to assuring that counseling services are provided according to the individual and treatment plan updates. All staff will be directed to schedule clients according to their treatment recommendation and document weekly on the client record of service. Any deviation from the set course of treatment will also be documented on the record of service. The Clinical Supervisor will review treatment plans recommendations and compare it to the record of service for compliancy during the CQI process monthly. Clinical staff will be monitored monthly in regular supervisory sessions.
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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 the review of client records, the facility failed to ensure that a complete record was documented in four of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a complete client record were reviewed on 5/1/2015. The facility failed to document a complete record in client records # 5, 7, 8 and 9.
Client # 5 was admitted on 6/30/2014 and discharged on 4/17/2015. There was no documentation of a record of service for February 2015, March 2015 and April 2015 in the client's record. Furthermore, there was not a discharge summary documented in the client's record at the time of inspection.
Client # 7 was admitted on 8/29/2014 and discharged on 2/9/2015. There was no documentation of a record of service for October 2014 and December 2014 in the client's record.
Client # 8 was admitted on 4/14/2015 and was an active client at the time of inspection. The client attended an individual therapy session on 4/14/2015 as per the record of service. There was not progress note documented in the client's record for this individual therapy session.
Client # 9 was admitted on 11/28/2014 and was an active client at the time of inspection. There was no documentation of a record of service for April 2015 in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on June 19, 2015 to address clinical staff on treatment management procedures specific to client records. All staff will be directed to update the client record of service per the treatment plan recommendation and to include all attendance cancellations and/or no shows. Each month the client is active in treatment will be reflected by client record of service. Clinicians will be directed to support each service by written progress note.
Upon discharge clinicians will be directed to complete all required paperwork within the 7 day timeframe.
The Clinical Supervisor will review charts monthly to ensure compliance through the CQI process. Staff will be reminded to review the facility mock chart. Clinical staff will be monitored monthly in regular supervisory sessions.
Charts currently missing client record of service and/or discharge paperwork will be brought up to date by 6-30-15. Verification of documentation will be completed by Division Director or Administrative Manager and updated in the CQI system. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment and rehabilitation plans for medical assistance clients as required by the Office of Medical Assistance in one of five client records reviewed.
The findings include:
Five client records requiring a physician signature on individual treatment and rehabilitation plans were reviewed on 5/1/2015. The individual treatment and rehabilitation plans contained in client record # 7 did not contain a physician signature as required by the Office of Medical Assistance.
Client # 7 was admitted to outpatient treatment on 8/29/2014 and discharged on 2/9/2015. The client's individual treatment and rehabilitation plans dated 9/25/2014 and 11/28/2014 did not include a physician signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective May 29, 2015 all outpatient charts will be reviewed on a monthly basis specifically focusing on obtaining physician signature on all treatment plans. Administrative staff will review charts monthly to ensure compliance through the CQI process. |